Message From Your Region 7 Representatives: Robert Kiesecker and Sandra Pedersen
For many coders determining how to approach an unfamiliar operative report can be a daunting feat. For many of us, we get familiar with our area of expertise and we are hesitant to venture out. However, regardless of the specialty or our expertise, there are a few tips to keep in mind when approaching a foreign coding situation.
1 Remember the right code is right in front of you…
When I first started down the path of coding it always seemed to put me at ease to remember that the correct code was somewhere in the book that was in front of me, all I needed to do was find it. Many instructors refer to this as the process of elimination, if you identify what group of codes are not possibly correct then it narrows the window to the potentially correct code.
2 Remember the Diagnosis
The diagnosis is important for many reasons. The most obvious is that it demonstrates the medical necessity for the procedure or test. Less obvious is that the diagnosis helps to narrow down your search for the procedural code. Knowing what is wrong with the patient allows you to possibly know what needs to be done to correct the ailment, which gets you that much closer to the correct code.
3 Understand approach and type of procedure performed
Patients can be placed in many different positions in order to perform the needed procedure. The placement of the patient has a major effect to understanding the procedure being performed, as well as being a component of the correct code. It is also important to understand if the procedure is an open or closed procedure. Did the provider use or mention using a scope, mirrors or contrast? These indicate the procedures is closed and it is important to find the code they reflect. Closed procedure can evolve to open or the procedure may start as being open. Open procures typically have longer global periods and longer recovery time. Understanding the type of procedures and what approach the physician took can provide yet another way of narrowing your search.
4 Identify complications and laterality
By this point in most cases the correct code is likely narrowed down or already identified. Any complications that occur during the procedure may warrant the need of using a modifier. You may need to indicate the procedure was more complicated or that it is needed to perform addition surgeries in a staged approach. Depending on the complication, the provider may not have been able to complete the procedure fully. This too would require the use of a modifier to adequately code the procedure correctly. Additional laterality and anatomical modifiers can and should be used to further code the procedure correctly.
5 If all else fails, use your network
Being a member of one of the largest professional certification organizations in the country has its perks. There are many opportunities to utilize the extensive network of coders to assist you with your coding needs. When I am struggling to find a correct code, I check the AAPC forums. Even if the info is outdated it often gets me in the right ball park to find my code. Local chapters are also a great resource. Bring your coding situation up at a chapter meeting, this can lead to a direct help or the contact information for someone that may be able to assist with that specialty. This also typically leads to your chapter officers seeking speakers that can provide even more info on that topic
Coding a new specialty can be challenging at first. Hopefully the above tips assist you in correctly coding any procedure and gives you a foundation to start. The only constant in our field is that it is constantly changing. There are always new challenges that face us. It is important that, as a certified professional, we remember that we have the ability to face these challenge and identify the solution regardless of the difficulty.
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