Reader’s Question – How do I put it all together?

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Question from Member “K”:

I completed my coding school and passed the certification test.  I did well on an interview, but I failed the employment test.  The test was not multiple choice, I had to pick the codes myself, and they didn’t even have an encoder.  How do I put it all together to get the codes?

Warning, lengthy editorial.  Get your coffee!

I’m sharing this with the group because I know other new coders have had similar experiences.

My words may sound harsh, but you need to hear them.  Welcome to the real world of coding. 

Yes, we usually have access to encoders when coding, and there are a few good encoders that will assist you; however, as the coder, you have the responsibility to validate the codes suggested by the encoder to ensure that the documentation supports the codes (CPT, HCPCS, ICD).

In the event the encoder is down, coding production must continue.  So, you must know how to use your books to: 

• Understand chapter-specific guidelines
• Recognize and follow tabular notations in ICD-10 for inclusions, exclusions, code first, use additional, and code also.
• Understand ICD icons and color bars that identify age and sex edits and manifestation codes.
• Identify and correctly report with CPT, add-on services, codes that are modifier 51 exempt, and codes that may be used to report telemedicine services.

I am so sorry your coding course did not better prepare you for real-world, hands-on coding that will never include multiple choice answers.

I declined an opportunity at a local community college to teach coding students how to use an industry-standard encoder.  In my professional opinion, coders should first master coding from their books.

So, Member “K,”

When abstracting codes (CPT^® or ICD), you’re telling the story of what, how, and why the service was performed.

I always say we are translating the documentation to codes that payers and other agencies universally understand.

With CPT^® codes, we’re telling what was performed and how it was performed (procedure code)

Suppose the procedure was changed from how the code describes it, or the provider documents more detail than what is represented by the code.  In that case, we have to add a modifier(s) unless, of course, there’s another CPT code to describe the modified work.

I’ll do more blogs on modifiers.  Stay tuned.

We report ICD-10-CM codes to tell why the procedure was performed.  The diagnosis code(s) describe the sign/symptom, condition, or circumstance that requires study.

We report additional diagnoses to further support medical necessity, such as chronic conditions, cause, and place of injuries, family or personal history of diseases or conditions that may impact the reason for the current study or procedure or social determinants of health.

Category II HCPCS codes are used to report drugs, medical and surgical supplies, durable medical equipment, dental procedures, to name a few.

In short (too late for that, huh?), we put it together to relay the story of the encounter or procedure in a language known as codes.

I recommend, “K,” that you find a mentor, attend local chapter educational events, participate in coding webinars and seminars, enroll in a coding Bootcamp (not a Bootcamp to prepare for the certification exam), and find sample medical records online (through your certifying organization) to practice.

ICD-10® is copyrighted by the World Health Organization (WHO)

ICD – ICD-10-CM – International Classification of Diseases …. https://www.cdc.gov/nchs/icd/icd10cm.htm

CPT^® is a registered trademark of the AMA

Learn the history and purpose of CPT®

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Have you thought about how or why CPT codes are developed?

Well, the AMA has a training module that will review the history and purpose of CPT^®.

Just sign in (or create a free account), and you will have free access to this module (any many more) that will assist you in achieving the following objectives:

“1. Recall the purpose and history of the Current Procedural Terminology (CPT) code set
2. Describe the objective and structure of the CPT Editorial Panel and supporting committees and workgroups
3. Identify the key CPT components
4. Recognize how and where CPT is used in the health care ecosystem”

Stay in your lane

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When I meet with providers, I always start by telling them that I am not qualified to assess the care they provide to their patients, but I am qualified to evaluate the quality of their documentation.

As coders, unless you are also a clinician, we are not qualified to “treat” patients.  We are not qualified to challenge how a clinician treats patients.

Unless we have medical backgrounds, we cannot question the provider’s clinical judgment – that would be a peer review, and we are not the clinicians’ peers.

We are coders.  Whether your title is Coder, Auditor, Provider Educator, Coding Consultant, or any other coding label, you’re a coder.

Your credential means that you can compliantly translate the clinician’s documentation into codes.

Coding or auditing records does not mean that you are qualified to treat patients or assess patients’ quality of care.

 I have performed shared audits with clinicians.  My responsibility is to audit the coding while the clinicians review the records for medical necessity and quality of care.

I audited one physician who instructed a patient to drink her first urine of the day.  I thought it was weird, but hey, I’m just a coder.

So, why am I sharing this?

I audited an auditor, and most of her “findings” were not coding-related.  She made a lot of comments on providers’ quality of care.

No, she’s not a clinician.  She does not have a medical background, and she’s not a Clinical Documentation Specialist.

Her logic was since she’s reviewed thousands of medical records (for coding purposes), she’s well versed in how the patients should be managed.

This is one of the reasons why physicians have issues with coders!

Stay in your lane!