Wiki What strategies do you use to code more efficiently?

Elund

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And what do you recommend to medical coders in general?
 
Elund:)
If abstracting medical codes for certain specialty learn abbreviations, slang terms, modifiers and Z dx codes related to that specialty such as Orth, OB-GYN, Family Med, Gastro Etc. They need to learn basics and understand READING & coding concepts of the differ areas of ICD10and CPT manuals help a lot. Also help understand bundling in CPT code usage and Excludes Rules 1 vs 2 and when to add comb codes for certain diseases and level or stages of disease. But it depends on providers documentation and type of medical encounter/visit.(New, vs Est outpt., vs surgery, vs INPT vs follow up vs Xrays and labs, preventive services)
I hope helped you!:)
Lady T
 
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Elund
If outpt. record first for look for nature of complain , is it type of session ( Est or new or follow up Etc) visits. Then look at review of system ROS see if mentioned the problem and specify details. Hopefully the provider has given coder/reader description of treatment suggested, meds or ancillary testing wants completed. Then at ending is the assessment or dx list which if giving meds but if stable and no meds...I d not code it. Also, if look at medical history I'd add history code if pt had illness but gone now.....use dx Z85-Z87 code corresponds to current illness. And if provider reviews medications or prescribed meds check to add Z51.81 or Z76.00 as last dx code
Or look at procedures and final dx codes given to see if supported in documentation
I hope helped you
Lady T
 
And what do you recommend to medical coders in general?
One way to code more efficiently is to use tools that combine coding guidelines, payer policies and quick code lookup features all in one place like https://codebooks.rapidclaims.ai/ .These kinds of resources can save a lot of time when you’re working through complex cases or need to confirm specific codes. Having something that simplifies the search process and supports accuracy can make a big difference in your workflow.
 
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