Coding from doctor's notes


Severna Park, MD
Best answers
I am a new coder, and still have trouble coding from the description in doctor's notes. I need more practice in what is coded and what is not. I try to look at the description of the code, to see what it includes, but I still need some help. Any hints? I keep being told I just need to practice, practice, practice, but without a job, I'm still struggling.:confused:
Response to coding from dr's notes

Hi. I suggest capturing procedures, labs, etc. If you can capture what procedures, lab work (done in the office), etc, if any, that will at least help. Medicare has this guideline sheet to help with E/M level. If I have confused you at all, just let me know or send me an email Hope this helps.
your definatly gonna look out for any procedures they have done, if they charge for specific labs, ekgs, xrays,etc.. most physicians that i have come across are pretty straight forward in telling you in what they do or do not charge for.. so those are the things you are looking for.. i hope that helps.. if your not sure if they charge for it dont be afraid to ask..