Code With Confidence

Code With Confidence

7 steps to set you down the path to coding claims with certainty.

It has been my experience — both personally and through the medical coders I’ve had the pleasure of training — that we all suffer from a lack of self-confidence to varying degrees. The trap of self-doubt is real. We endure pressure daily through production and accuracy standards and criticism of our work by auditors, payers, and managers. Thankfully, there are ways to combat this trap while simultaneously improving our coding skills.

How Confident Are You?

On a scale of one (not confident at all) to 10 (maximum confidence), how confident are you when it comes to coding? Most of us probably land somewhere in the middle of that scale. There’s so much to know when it comes to coding that it’s nearly impossible to be 100 percent confident all the time. If you are lucky enough to fall into the “maximum confidence” category, then congratulations! I’m not only envious, but also in awe. For everyone else, let’s look at some actions you can take to become a more confident coder.

1. Know the Rules

The first three steps to take toward being a more confident coder are:

  1. Know your coding guidelines.
  2. Know your coding guidelines.
  3. Know your coding guidelines.

That sounds like a broken record, but I can’t stress this enough. Knowing the coding guidelines is the very backbone of our profession. Coding guidelines and the concepts within them will help you be confident in your code selection, especially when faced with complex coding scenarios.

Changes are made to these guidelines annually, at a minimum, so you should review all coding guidelines at least once a year. Reviewing previous guidance is important, as well. I suggest reading a coding guideline or chapter-specific rule that pertains to a chart you are working on currently. For example, if the chart in front of you requires the capture of an alcohol-related diagnosis code, then read the chapter-specific guidelines for Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders. Pay special attention to the proper usage of “use, abuse, and dependence,” even if you think you know the answer. Repetition and memorization improve speed, strengthen the connections in your brain, and increase confidence.

2. Follow the Rules

Once you have a good understanding of the guidelines, the next step is to follow the rules. This may sound elementary but, as we all know, the guidelines are often difficult to follow. If you don’t follow them, however, you will undoubtedly end up with an inaccurate code selection. Here is an example of how to select an ICD-10-CM code:

Step 1: Locate the condition in the Alphabetical Index. After locating the main term, review the sub-terms to find the most specific code available. Note any other clues to proper coding, such as cross-referencing, the need for additional characters, and other instructional notes.

Step 2: Verify the code in the Tabular List and identify the highest specificity. Read the full code descriptor.

Step 3: Review the chapter-specific coding guidelines and follow the code’s instructional notes to make sure you’re meeting all the code requirements. Notes provide guidance such as the need for additional characters or codes. These notes and instructions are on every level, from the chapter to the code itself.

Step 4: Code to the highest degree of accuracy and completeness.

Step 5: Take a moment to confirm that your code choice complies with the philosophy of ethical coding. Report only those codes the documentation supports.

You must follow these basic rules to ensure accurate and ethical coding. As a professional coder, it is your responsibility to understand and follow coding rules, conventions, and guidelines. Ethical coding means conforming to accepted standards of conduct. The best piece of advice I’ve ever received is to never code something I cannot defend.

3. Further Your Education

Above knowing and following all the coding rules, successful and confident coders should be on a never-ending journey of learning. Your education does not stop when you pass the Certified Professional Coder (CPC®) exam; in fact, your learning has just begun. The healthcare industry is ever-changing, and keeping up with all the applicable changes is imperative.

Consider taking courses that focus on human anatomy and physiology, specific disease processes, medications, and medical terminology. Understanding medical documentation, more than just knowing how to find the right code, can aid you in coding complex cases. AAPC offers numerous webinars that provide helpful information, such as their Anatomy and Pathophysiology Series. Expand your horizons by studying for additional credentials, as well.

4. Learn to Think Critically

If you chose medical coding because you thought it would be a black-and-white, right-or-wrong type of job, I have some bad news for you. Medical coding has many gray areas where there is no straightforward answer to a coding scenario, making critical thinking essential.

Understanding is acquired by making connections between ideas and concepts. Successful coders use critical thinking skills by actively applying all their knowledge — coding guidelines and authoritative resources, anatomy and physiology, disease processes, etc. — to analyze the medical documentation and select the code that best describes the condition or service.

5. Stay Positive

Coding is a very complex process, and this complexity results in many challenging situations. Being a confident coder takes hard work, effort, and time. There are thousands of codes, hundreds of rules, and a million different ways doctors document.

Mistakes will happen with even the most experienced coder. If you make a mistake, correct it. Learning from mistakes is essential to becoming a better coder.

Stop any negative self-talk, as it limits personal growth. Instead, focus on the solid skills you have and the milestones you’ve reached. Think about what you can do, not what you can’t. A positive attitude will make it easier for you to learn new concepts.

6. Practice, Practice, Practice!

Expanding your knowledge and developing critical thinking skills is like strengthening your muscles — the more you use them, the stronger they get. This means spending time learning above and beyond your eight-hour shift at work. Read Healthcare Business Monthly; earn more than the minimum required continuing education units (CEUs); attend your local chapter meetings; subscribe to other credible resources such as the American Hospital Association’s Coding Clinic or the American Medical Association’s CPT® Assistant.

7. Have a Support System

Feeling confident in your skills and the coding decisions you make is important, but collaboration with other coders has its benefits. Cultivate a few close relationships with coworkers or colleagues whom you trust will provide valuable insight and feedback. Please remember, however, that any coding advice not from an official source should be considered opinion.

What Are the Benefits?

After all this hard work, be ready to reap some hard-earned rewards! Some of the advantages of being a confident coder include:

  • Easily attainable accuracy goals
  • Improved productivity
  • Promotion and pay raises
  • Increased autonomy
  • Better work relationships
  • Positive attitude
  • Less stress and anxiety

Tackling difficult coding scenarios can be frustrating. The keys to success and becoming a confident coder are having the right attitude, being motivated to continually improve your coding knowledge and skills, and being open to change based on new information.

Remember, you are responsible for your own growth as a coder. As you take action to improve your skills, you will undoubtedly move up a notch or two on that one to 10 confidence scale!

Melissa James, CPC, CPMA, CRC
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Melissa James, CPC, CPMA, CRC, has more than 20 years of healthcare experience in coding, billing, physician and coder education, accounts receivables management, compliance, and consulting. She received her associate degree from Pueblo Community College. James is a member of the Pueblo local chapter in Pueblo, Colo.

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