The key to cooking any great meal begins by starting off with the right ingredients. We first locate a recipe (or for those of you more culinarily creative than myself, you may create your own). Next we need to schedule a trip to the grocery store to make sure we have all the required ingredients on hand. When it comes time to cook this fabulous meal, we have to measure the correct amount of each ingredient and follow the recipe step by step in a methodical manner to ensure the outcome is what we intended.
When it comes to medical coding, the step by step mechanism for coding accurately works much the same way, but so often, we don’t break down the process of accurately coding one step at a time. So many coders I have talked to feel like they should simply “know” the correct code the first time they attempt to code a new specialty or procedure, or they go searching for a resource that will give them the right code without developing the ability to discover the right code on their own.
While this method of finding someone who knows the answer and following their lead can be effective at times, particularly when you are too new to a specialty to even know what it is you need to start searching for, the key to really learning your specialty and developing an ability to navigate new and unfamiliar procedure notes with ease lies in the quality of your research and the steps you take to break down a note one step at a time. Here are some tips to get you on your way to researching like a pro!
- Look up terms that are unfamiliar to you. Understanding a really complex note starts by understanding the individual terms in the report that bring meaning to where the provider is working anatomically, the disease/condition that prompted treatment, and how the anatomy changes after the procedure. Google is your friend when searching medical terminology. There are many great medical dictionaries available online, and when it comes to just getting a definition of a word, even Wikipedia can be useful if you use it with caution. My litmus test when searching for definitions of a medical term is to look at 2-3 different sites and see if the definitions being presented are all consistent. If they are, I have my answer; if they are not, it’s a sign that I need to keep researching to gain a better understanding of the term.
2. Watch online videos of complex surgical procedures that are unfamiliar to you.
Yes, I just cited You Tube as a potential resource. While I would certainly be hesitant about taking “how to” coding advice from random individuals online (see point #3 below), if you are simply trying to visualize a procedure or a portion of a procedure in your mind, and getting lost in the words of the operative report, You Tube and other similar sites have some invaluable resources that can help you picture what the surgeon is trying to describe. This method of researching a procedure is particularly effective if you are a visual learner. As an example, check out this video about a lumbar interbody spinal fusion procedure (for the squeamish among us, no fear, the video is entirely digital :)): Interbody Fusion.
3. Don’t believe everything you read on the internet.
Here is the disclaimer statement to points 1 and 2 above. Be careful about taking coding advice from just anyone on the internet. While it is always nice to be able to access a free site where coders network and help each other out, there are times where the advice provided, while well-intended, is not in alignment with the guidelines from governing bodies like the AMA, CMS, and the specialty societies such as AAOS, AUA, etc. A red flag for me is when someone’s advice starts with “well I’ve always done ____ and never had an issue”; or “in my opinion”; or “I feel _____.” Those statements are made from a point of subjectivity rooted in the individual’s personal experience and that does not make the guidance that follows these statements correct. Instead, look for sources that cite the guidelines that support the advice they are providing. Examples include “per the NCCI policy manual, chapter 6, section E…”; or “CPT guidelines state”; or “see the CMS Claims Processing Manual, chapter 12, section 30.6 for details.” These types of statements generally indicate that the person providing the guidance has done their research and is referencing a guideline from a governing body that would hold up in the event of a potential audit. By providing their source as well, the person providing the guidance is offering you as an individual the opportunity to go check out the guideline for yourself and verify the guidance they have provided you. Take full advantage of that opportunity! Question everything and take the time to do the legwork and research yourself because, at the end of the day, you are the only person who will answer for your own coding.
