Internal Medicine Coding Alert

Internal medicine coders will find it easier to do their jobs efficiently if they have the proper resources on their desks and at their fingertips.

Following are some recommendations from three experienced professional coders: Jan Rasmussen, CPC, president of the Eau Claire, Wis.-based Professional Coding Solutions, which provides coding support, compliance review and contract coding to physicians nationwide, and a member of the AAPC National Advisory Board and the AAPC liaison to the American Medical Association; Carol Sissom, CPC, a senior healthcare consultant at the Indianapolis-based Health Care Economics Inc., which provides billing and coding services to 200 practices annually; and Joan Peters, CPC, CHCC, director of business operations at Bassett Healthcare in Cooperstown, N.Y., which supports about 200 providers.

In addition to picking their favorite traditional references and coding guides, these coders share some additional ideas ranging from the high-tech (Web sites) to the high-touch (face-to-face meetings with payers).

Most coders need a variety of medical references to help them understand the terms, anatomical references and acronyms used by physicians. "Unless you have a clinical background, you just won't know all the terms the doctors use," says Peters.

Medical dictionary. Peters recommends Dorland's Illustrated Medical Dictionary, while Sissom finds Taber's Cyclopedic Medical Dictionary more user-friendly if the coder does not have a clinical background.

General anatomy and physiology book with drawings. A book showing the body's anatomy in detail will help if the physician mentions a specific body area in his or her notes and you don't know where it is located. For example, the physician discusses the deltoid muscle, but you aren't sure which part of the shoulder or arm contains that muscle. Two recommended resources are Atlas of Human Anatomy by Frank Netter and Gray's Anatomy by Henry Gray.

Other references on medical language. Rasmussen says she often uses The Merck Manual, which provides helpful information on the diagnosis, pathology and treatment of disease, and also finds The Language of Medicine by Davi-Ellen Chabner helpful in deciphering the terminology of medicine.

Dictionary of medical abbreviations. Sissom recommends The Dictionary of Medical Acronyms and Abbreviations, published by Hanley and Belfus Inc. (www.hanleyandbelfus.com). This resource is helpful when the physician uses abbreviations the coder does not understand. For example, it will tell you that "perrl" means "pupils equal, round and reactive to light."

Drug references. Physicians' Desk Reference and Physicians' Desk Reference for Nonprescription Drugs and Dietary Supplements, which provide information on prescription and over-the-counter drugs, including therapeutic dosages and side effects, are useful in choosing proper codes when a patient has a drug reaction such as a rash, or a poisoning.

Online option. If your bookshelf is beginning to look crowded, consider using online versions of some references. You can find both a medical dictionary and a medical encyclopedia online at www.nlm.nih.gov/medlineplus.

To use codes properly, coders need the most up-to-date information available:

CPT, ICD-9-CM and HCPCS manuals. Buy these manuals annually. "I'm amazed that some offices don't do that," says Peters. "They think there aren't that many changes." However, there are major changes each year. Outdated codes can lead to claim rejections.

CPT Changes. This guide, published annually by the American Medical Association, describes in detail every CPT code that has been changed and explains how to use it properly (www.ama-assn.org).

Coders' Desk Reference. This book, published by Medicode (www.medicode.com), describes all CPT codes in detailed layperson's terms and gives appropriate uses. Sissom says this can be very helpful when the coder is unsure exactly what is encompassed in a particular code.

The Coding Institute newsletters and discussion groups. In addition to publishing this newsletter, The Coding Institute hosts discussion groups and publishes newsletters addressing coding issues for other subspe-cialties such as cardiology, gastroenterology and pulmonology. "We're multispecialty, and we get all the Coding Alerts," says Peters. "They are a good tool to alert people to changes." Visit www.codinginstitute.com.

CPT Assistant. This monthly newsletter published by the AMA provides detailed advice on using procedure codes (www.ama-assn.org/med-sci/assist.htm).

AHA Coding Clinic for ICD-9-CM is a quarterly newsletter published by the American Hospital Association (AHA) and can be found at www.ahaonlinestore.com.

Correct Coding Initiative edits. Sissom suggests buying the government version of this book, which provides updated information on when unbundling is appropriate. It can be purchased in whole, or in sections if you don't need information in all areas of medicine. Internal Medicine Coding Alert also informs readers every quarter of changes that apply to internists.

Get to know your payers and the resources they offer on coding topics: