Are you sure you’re doing it right?

Featured coffee – Bee Bold Dark Roast
“Coffee Benefiting Defenders of Wildlife”

A coder said that learning to code from the coding books is more challenging than coding in real life.

I couldn’t process what she said, and I had to ask the coder to clarify her statement.

According to the coder, she learned to code from her books in class.  Using her books meant that she had to look up the terms, interpret the guidelines, code first, code also, check NCCI edits, check for bundling edits, sequence correctly, and link diagnosis code(s) to CPT code(s) (among other things). 

When she sat for her coding certification, she also had to use her books.

It’s called manual coding, people! It is “real-life” coding.  It’s what we all did before encoders and other coding software was around.  It’s also what we do when the system is down, and coding production has to continue.

As an employee, the coder uses an encoder or other coding software instead of her books.  She enters keywords, selects options from drop-down menus, answers a few questions, and the encoder suggests CPT, HCPCS, ICD, and modifiers.

But, if one answer or term is entered incorrectly by the coder, the software may suggest an incorrect code.

Computer-assisted coding suggests codes from keywords in the documentation, and the coder either agrees with the codes or makes changes.

By the way, I have audited coders who used computer-assisted coding software and failed them because they agreed with whatever incorrect codes were auto-suggested.

If you’re using an encoder or computer-assisted coding software, you have to have the coding knowledge to validate the codes suggested by the encoder.   

As I wrote in Encoder Dependent,

The coder is either not gaining, or is losing coding knowledge.  The coder will not know or will forget general coding and chapter-specific guidelines.  Will the coder know a code has an age or sex restriction? Will the coder know the difference between Exclude 1 versus Exclude 2? Will the coder know the code cannot be reported as a primary diagnosis? Will the coder understand etiology/manifestation coding rules and the importance of sequencing? Will the coder be able to follow the code-level notations?

So, no.  Whether you’re using an encoder or coding from your books, real-life coding is challenging.

Guest Post

Featured Coffee – Save Our Wolves – Dark Roast

Our friend, Victoria Mallory, stopped by to share her opinion on an article that she read.

I wanted to share an article I recently came across in AAPC’s “Healthcare Business Monthly” regarding visualization for minimally invasive procedures.

This article provides excellent explanations of the different types of visualization used with sacroiliac fusion and other spine examples.

The graphics are worth saving for future reference when considering code choice(s) for orthopedic procedures. 

Happy National Medical Coders Day!

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Mental Health Awareness Month

Featured coffee – Chocolate Beignet

2021’s Mental Health Awareness Month message is “You Are Not Alone.”

In our roles as Coders, Auditors, and Educators, we are not healthcare workers, but all day, we are reading stories of patients and families at their most personal and vulnerable times.

Our job is to translate the notes to codes, but we’re human.  In my circle, each of us has read a record and could either be that patient or have a loved one who could be that patient.

Early in my career, I decided I did not want to code Pediatrics or Pediatric Surgery.  As a mother of a young child, I cried reading how a surgeon described a child’s intestine dying. 

Yes, everyone told me not to internalize what I was reading, but how do you not? No one shared how to turn off my emotions when reading notes. 

Decades later, have I found a way not to become emotional when coding/auditing records?

No, but I have found ways to feel what I’m feeling, openly discuss what I’m feeling with my circle, and move on.

The emotional impact of medical coding is not usually discussed.  We openly discuss the stress and demands of our jobs, but not the emotional impact that we endure.

First, acknowledge what you are feeling and then reach out for support.

Remember, “You Are Not Alone”