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Newbie Medical Coding for Beginners (Start Here)

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Are you new to medical coding & want to understand more about it? Then these NEWBIES threads are for you!

The first question most new coders (newbies) ask is...

What is Medical Coding?

About Medical coding:

The Bureau of Labor Statistics expects medical coding & billing jobs to grow at a rate of 21 percent through 2020, 11% higher than the average growth rate for the American economy.

Some great reasons to pursue medical coding jobs can include job security, good pay, and flexibility. Medical technology advancement has greatly contributed to the number of medical tests, treatments and procedures that are performed by healthcare providers. As a result, scrutiny of these medical records by regulators, payers and patients, continues to increase. So, medical coding jobs will continue to be a growing job field. Medical Coders can help to expedite medical claims through the system accurately and efficiently.

What Does A Medical Coder Do?

When a patient sees a healthcare provider each visit gets coded for reimbursement purposes & sometimes data tracking. A healthcare provider reviews your chief complaint & medical history to assess your medical condition to determine a diagnosis & how to treat that diagnosis. The healthcare provider documents your visit for your electronic healthcare record to determine payments made to the healthcare provider via your healthcare insurance.

A medical coder utilizes medical coding manuals called the CPT (Coding Procedural Terminology), ICD-10-CM (International Classification Diseases) & HCPCS (Healthcare Common Procedural Coding System) to select specific numbered codes to describe every visit for reimbursement.

Medical codes translate from the medical record into these standardized codes that tell

the payers all the pertinent information needed to achieve the maximum reimbursement to the healthcare provider.

EHR (Electronic Health Record) or EMR (Electronic Medical record)

Provides necessary information needed for reimbursement:

Patient Diagnosis

Medically necessary treatments, services or supplies the patient received.

Any unusual circumstances or medical conditions that affected those treatments or services.

Keep Reading More Medical Coding Beginner Articles...
 
CONVENTIONS

The letters NEC represent the abbreviation “not elsewhere classifiable”. This simply means that the medical record provides detail for which a specific code does not exist in the ICD-10-CM manual. In other words, the book does not contain enough information to match the diagnosis code the provider has given.

The abbreviation NOS, “not otherwise specified” basically means the medical record is insufficient to assign a more specific code. In simple terms, the provider’s information is inadequate to locate a code.

When the term “and” is used in a statement, it may be interpreted as, “and/or”.

You will also find instructional notes that say code first or use additional code. These are sequencing instructions that must be followed.

A “code also” note alerts the coder that more than one code may be required to fully describe the condition.

A good tip to remember when looking up a code in the Alpha Index is to work from the right to the left. For example: Parkinson's Disease: look up “Disease” first, then “Parkinson's”
 
Sequencing matters:

  • Follow sequencing rules in coding guidelines and coding conventions. If there are code options with the same codes in a different sequence, pay close attention to the coding conventions and guidelines to guide you in the right selection. The basic ICD-10-CM conventions apply to all settings, so inpatient, outpatient, and professional service coders all need to know them. But coding guidelines can change depending on the setting. The Official Guidelines for Coding and Reporting have dedicated sections for guidance that is specific to individual settings. Sections II and III are inpatient coding concepts, while Section IV is limited to outpatient coding.
  • That can be a little confusing for coders who handle both inpatient and outpatient claims or for those who code for both facility and professional services. A coder at a small facility may report the facility portion of an inpatient admission, for example.
  • That same coder may then end up coding the evaluation and management professional services for one of the physicians who treated that patient in the hospital. The coder will still use the CPT® codes for the physician’s services.
  • Consider the following situation. A physician documents “probably blood loss anemia” as the reason for the inpatient admission. Coders in the professional services setting can’t assign a code for the probable diagnosis. Therefore, they would have to code based on the highest level of certainty, which could be as small as a symptom. “Even though you are coding for an inpatient in the hospital, you are coding for the professional services at that point.”

Sequencing codes


Many of the chapter-specific guidelines focus on the correct sequencing of codes and choosing a principal diagnosis. Those concepts are more important to inpatient coding and in fact, principal diagnosis is only used for inpatient admissions.

  • Inpatient coders need to review the record to determine why the patient was admitted and sequence the codes based on that information. Outpatient and physician services coders don’t need to worry about that.
  • Hospital inpatient and hospital outpatient coders have a different perspective on the importance of the order that the codes go in.
  • ICD-10-CM codes help support the medical necessity of services provided in outpatient and professional office settings. In those settings, coders need to link together the pertinent diagnosis with the procedure the physician performed.
 
Etiology and manifestation guidelines


Some conditions have both an underlying cause and affect multiple body systems. For these conditions, coders must follow the ICD-10-CM coding convention that requires the underlying condition be sequenced first followed by the manifestation. Coders will find a “use additional code” note at the etiology code, and a “code first” note at the manifestation code.

  • Most, though not all, manifestation codes say, “in diseases classified elsewhere,” Never code that first because these codes are part of the manifestation convention. The codes that don’t include this language generally say “use additional code” instead. The sequencing rules still apply.


  • In addition to the notes in the tabular section, these conditions also have a specific index entry structure. The index lists both conditions together with the etiology code first followed by the manifestation codes in brackets. Always sequence the code in brackets second.


  • Look in the alphabetic and numeric section to make sure you have the right number and mix of codes.
 
Chronic, acute, or both

Some conditions, such as bronchitis, can be acute or chronic. In some cases, a patient can have both an acute and chronic form of the condition.

  • Provided the physician has adequately documented the acute and chronic bronchitis, coders should report both because they are two different conditions. Report the acute condition first.
 
Parenthetical notes provide valuable information:

  • Paying close attention to information in the CPT® parenthetical notes prevents you from making coding errors. Example: There is a parenthetical note following code 10030 which states "Do not report 10030 in conjunction with 75989, 76942, 77002, 77003, 77012, 77021. This alerts the coder that imaging guidance cannot be reported with the surgical procedure code.
 
Know your modifiers:
  • Review the proper use for each modifier. Understand when each should be appended.
  • 22 Increased procedural services
  • 23 Unusual anesthesia
  • 24 Unrelated evaluation and management service by the same physician or other qualified professional during a postoperative period.
  • 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service.
  • 26 Professional component.
  • 32 Mandated services.
  • 33 Preventative services.
  • 47 Anesthesia by surgeon.
  • 50 Bilateral procedure.
  • 51 Multiple procedures.
  • 52 Reduced services.
  • 53 Discontinued procedure.
  • 54 Surgical care only.
  • 55 Postoperative management only.
  • 56 Preoperative management only.
  • 57 Decision for surgery.
  • 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period.
  • 59 Distinct procedural service.
  • XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
  • · XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure,
  • · XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and
  • · XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.
  • 62 Two surgeons.
  • 63 Procedure performed on infants less than 4kg
  • 66 Surgical team.
  • 76 Repeat procedure or service by the same physician or other qualified health care professional.
  • 77 Repeat procedure by another physician or other qualified heath care professional.
  • 78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period.
  • 79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period.
  • 80 Assistant surgeon.
  • 81 Minimum assistant surgeon.
  • 82 Assistant surgeon (when qualified resident surgeon not available).
  • 90 Reference (outside) laboratory.
  • 91 Repeat clinical diagnostic laboratory test.
  • 95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.” Modifier 95 is only for codes that are listed in Appendix P of the CPT manual
  • 99 Multiple modifiers.

  • Anesthesia Physical Status Modifiers

  • P1 A normal healthy patient.
  • P2 A patient with mild systemic disease.
  • P3 A patient with severe systemic disease.
  • P4 A patient with severe systemic disease that is a constant threat to life.
  • P5 A moribund patient who is not expected to survive without the operation.
  • P6 A declared brain dead patient whose organs are being removed for donor purposes.

Additional Healthcare Common Procedure Coding System (HCPCS) Modifiers

AE, AF, AG, AI, AK, AM, AO, AT, AZ, BL, CA, CB, CG, CR, CS, CT, DA, ER, ET, FB, FC, FX, FY, G7, GC, GE, GG, GJ, GU, J1, J2, J3, JC, JC, JD, JG, JW, KX, L1, M2, PD, PI, PO, PN, PS, PT, Q0, Q1, Q3, Q4, Q5, Q6, QQ, RD, RE, SC, SF, SS, SW, TB, TC, TS, UJ, UN, UP, UQ, UR, US, X1, X2, X3, X4, X5, XE, XP, XS, XU, ZA, ZB, ZC

Advance Beneficiary Notice of Noncoverage (ABN) Modifiers

GA, GX, GY, GZ

Advanced Diagnostic Imaging Appropriate Use Modifiers

MA, MB, MC, MD, ME, MF, MG, MG, MH, QQ

Ambulance Modifiers

D, E, G, H, I, J, N, P, R, S, X, GM, QL, QM, QN

Anatomical Modifiers
(Coronary Artery, Eye Lid, Finger, Side of Body, Toe)

E1, E2, E3, E4, FA,F1,F2,F4, F5, F6, F7, F8, F9, LC, LD, LM, LT, RC, RI, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9

Note: These modifiers should be used in place of modifier 59 whenever possible.

Anesthesia Modifiers

AA, AD, G8, G9, P1, P2, P3, P4, P5,P6, QK, QS, QY, QX, QZ, 23, 33

Assistant at Surgery Modifiers

AS, 80, 81, 82

End Stage Renal Disease (ESRD) and Erythropoiesis Stimulating Agent (ESA) Modifiers

AX, EA, EB, EC, AY, ED, EE, EJ, EM, G1, G2, G3, G4, G5, G6, GS, JA, JB, JE, V5, V6, V7, V8, V9

Global Surgery Modifiers

24, 25, 54, 55, 57, 58, 78, 79

Note: Modifiers 24, 25, 57 apply to evaluation and management services

Hospice Modifiers

GV, GW

Laboratory Modifiers

90, 91, 92, LR, QW

Other Current Procedural Terminology (CPT) Modifiers

26, 27, 33, 59, 76, 77, 95, 96, 97

Podiatry Modifiers

Q7, Q8, Q9

Quality Reporting Incentive Programs Modifiers

1P, 2P, 3P, 8P, AQ, AR, MA, MB, MC, MD, ME, MF, MG, MH, X1, X2, X3, X4, X5

Surgical Modifiers

22, 50, 51, 52, 53, 62, 66, 73, 74, PA, PB, PC

Telehealth Services Modifiers

GQ, GT, G0 (zero)

Therapy Modifiers

GN, GO, GP, KX, CO, CQ
 
History & Physical Examination

The history & physical examination is reviewed to learn more about why the patient was admitted to the hospital and to get an idea of the initial diagnostic and treatment plans.

Diagnoses documented in the history & physical examination report are tentative, and they are almost never coded as discharge diagnoses.

An exception would be "personal history of" or "family history of" codes, which are assigned for data capture for research and education.

Another exception is chronic conditions (e.g., hypertension, chronic asthma, diabetes mellitus, COPD, and so on) for which the patient requires medically management during the inpatient stay (e.g., diagnostic tests, administration of medication by nursing staff, and so on). In the history & physical examination below, you will notice that the patient's brother has been diagnosed with epilepsy. You will also notice that the patient has a history of smoking cigarettes. Assigning codes to family history of and personal history of conditions is permitted because they do not impact the DRG assignment (or increase the reimbursement rate).

EXAMPLE―FAMILY HISTORY OF:

The patient receives inpatient treatment for acute bronchitis, and upon review of the patient record the coder notices that there is a family history of lung cancer. Because both conditions are associated with the respiratory system, assigning a code to the family history of lung cancer is appropriate (in addition to a code for acute bronchitis, which is sequenced as the principal diagnosis).

EXAMPLE―PERSONAL HISTORY OF:

The patient undergoes inpatient treatment for cerebral aneurysm, and upon review of the patient record the coder notices that the patient has a personal history of traumatic brain injury because the patient was in a vehicle accident 10 years ago and sustained a fractured skull, concussion, and brain hemorrhage. Because both conditions are associated with the brain, assigning a code to the personal history of traumatic brain injury is appropriate (in addition to a code for cerebral aneurysm, which is sequenced as the principal diagnosis).

NOTE: Students and new coders often struggle with the decision if to assign codes to family history of and past history of conditions. The good news is that even if you mistakenly assign family history of and personal history of codes based on documentation in the patient record, the codes do not impact the reimbursement to the hospital. That means such codes are unlikely to be "counted against" the coder or the hospital as coding errors or fraud/abuse. To be sure, however, when on the job query your coding mentor or supervisor.
 
POA (Present On Admission)

All claims submitted for inpatient admissions to general acute care hospitals or other health care facilities are required to report the present on admission (POA) indicator, which is assigned by the coder to the principal and secondary diagnoses and external cause of injury code (E code) reported on the UB-04 or 837 institutional (electronic) claim.

The coder reviews the patient's records to determine whether a condition was present on admission or not. o Issues related to inconsistent, missing, conflicting, or unclear documentation are resolved by the provider because of the physical query process. In this context, present on admission is defined as present at the time the order for inpatient admission occurs. Thus, conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission upon admission of the patient as a hospital inpatient. CMS reporting options and definitions include the following:


Y = Yes (present at the time of inpatient admission)

N = No (not present at the time of inpatient admission)

U = Unknown (documentation is insufficient to determine if the condition was present at the time of inpatient admission

W = Clinically undetermined (provider is unable to clinically determine whether the condition was present at the time of inpatient admission or not)

1 = Unreported/not used (exempt from POA reporting; this code is equivalent to a blank on the UB-04; however, blanks are undesirable when submitting these data electronically.)


Admission Diagnosis

Principal diagnosis

Secondary diagnosis(es)

Comorbidity

Complication

Principal procedure

Secondary procedure(s)

Each type of diagnosis and procedure is defined.

Examples of each type of diagnosis and procedure are provided.

An image of an inpatient record face sheet highlights the location of each type of diagnosis and procedure.


Images of additional reports from an inpatient record highlight documentation that coders review to assign the most accurate and complete:

diagnosis code(s).

procedure code(s).


Admitting Diagnosis, the admission diagnosis (or admitting diagnosis) is the initial diagnosis documented by the:

Patient's primary care physician who determined that inpatient care was necessary for:

Treatment of a condition diagnosed in the office today (e.g., acute exacerbation of chronic asthma).

Elective surgery, which has already been scheduled (e.g., elective tubal ligation).
 
KEY CONCEPTS TO SELECTION OF PRINCIPAL DIAGNOSIS
  • The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care".
  • In determining principal diagnosis, the coding directives in the ICD-10-CM manuals, Volumes I, II, and III, take precedence over all other guidelines.
  • The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is a difficult, if not impossible, task.

Codes for symptoms, signs, and ill-defined conditions.
  • Codes for symptoms, signs, and ill-defined conditions from Chapter 16 are not to be used as principal diagnosis when a related definitive diagnosis has been established.

Codes in brackets.
  • Codes in brackets in the Alphabetic Index can never be sequenced as principal diagnosis. Coding directives require that the codes in brackets be sequenced in the order as they appear in the Alphabetic Index.

Acute and chronic conditions.
  • If the same condition is described as both acute (subacute) and chronic and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.

Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis.
  • When there are two or more interrelated conditions (such as diseases in the same ICD-10-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.

Two or more diagnoses that equally meet the definition for principal diagnosis.
  • In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.

Two or more comparative or contrasting conditions.
  • In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.

A symptom(s) followed by contrasting/comparative diagnoses.
  • When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as suspected conditions.

Codes from the Z series, Observation and evaluation for suspected conditions.
  • Codes from the Z series are assigned as principal diagnoses for encounters or admissions to evaluate the patient's condition when there is some evidence to suggest the existence of an abnormal condition or following an accident or other incident that ordinarily results in a health problem, and where no supporting evidence for the suspected condition is found and no treatment is currently required. The fact that the patient may be scheduled for continuing observation in the office/clinic setting following discharge does not limit the use of this category.

Original treatment plan not carried out.
  • Sequence as the principal diagnosis the condition which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances.

Residual condition or nature of late effect.
  • The residual condition or nature of the late effect is sequenced first, followed by the late effect code for the cause of the residual condition, except in a few instances where the Alphabetic Index or Tabular List directs otherwise.

Multiple burns.
  • Sequence first the code that reflects the highest degree of burn when more than
  • one burn is present. (See also Burns guideline 8.3)

Multiple injuries.
  • When multiple injuries exist, the code for the most severe injury as determined by the attending physician is sequenced first.

Neoplasms.
  • If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis, except when the purpose of the encounter or hospital admission is for radiotherapy session(s), Z51.0, or for chemotherapy session(s), Z51.11, in which instance the malignancy is coded and sequenced second.
  • When a patient is admitted for the purpose of radiotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal diagnosis is Encounter for radiotherapy, Z58.0, or Encounter for chemotherapy, Z58.1.
  • When an episode of inpatient care involves surgical removal of a primary site or secondary site malignancy followed by adjunct chemotherapy or radiotherapy, code the malignancy as the principal diagnosis, using codes in the 140-198 series or where appropriate in the 200-203 series.
  • When the reason for admission is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal diagnosis, even though chemotherapy or radiotherapy is administered.
  • When the primary malignancy has been previously excised or eradicated from its site and there is not adjunct treatment directed to that site and no evidence of any remaining malignancy at the primary site, use the appropriate code from the V10 series to indicate the former site of primary malignancy. Any mention of extension, invasion, or metastasis to a nearby structure or organ or to a distant site is coded as a secondary malignant neoplasm to that site and may be the principal diagnosis in the absence of the primary site.
  • When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.
  • Symptoms, signs, and ill-defined conditions listed in Chapter 16 characteristic of, or associated with, an existing primary or secondary site malignancy cannot be used to replace the malignancy as principal diagnosis, regardless of the number of admissions or encounters for treatment and care of the neoplasm.
  • Coding and sequencing of complications associated with the malignant neoplasm or with the therapy thereof are subject to the following guidelines:
  • When admission is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the anemia is designated at the principal diagnosis and is followed by the appropriate code(s) for the malignancy.
  • When the admission is for management of an anemia associated with chemotherapy or radiotherapy and the only treatment is for the anemia, the anemia is designated as the principal diagnosis followed by the appropriate code(s) for the malignancy.
  • When the admission is for management of dehydration due to the malignancy or the therapy, or a combination of both, and only the dehydration is being treated (intravenous rehydration), the dehydration is designated as the principal diagnosis, followed by the code(s) for the malignancy.
  • When the admission is for treatment of a complication resulting from a surgical procedure performed for the treatment of an intestinal malignancy, designate the complication as the principal diagnosis if treatment is directed at resolving the complication.

Poisoning
  • When coding a poisoning or reaction to the improper use of a medication (e.g., wrong dose, wrong substance, wrong route of administration) the poisoning code is sequenced first, followed by a code for the manifestation. If there is also a diagnosis of drug abuse or dependence to the substance, the abuse or dependence is coded as an additional code.

Complications of surgery and other medical care.
  • When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the 996-999 series, an additional code for the specific complication may be assigned.

Complication of pregnancy.
 
CODING FROM AN OPERATIVE REPORT

When you code an open procedure, you need to see the operative report, which includes the following:

The first step in abstracting the billable codes from the medical record of an open procedure is to identify which body part was treated & why. After you have identified that you know which area of the CPT book to check to begin the process of coding.

A preoperative, or preliminary, diagnosis is the diagnosis based on preoperative testing and pertinent physical findings observed by the physician during the examination

The postoperative, or definitive, diagnosis, is what the physician confirmed during the surgery.

Do not code from the outline in the report. These are merely previewing what is to come. For a procedure to be eligible for reimbursement, it must be documented in the body of the report.

A full report containing the surgeon’s description of everything that done during the operation.

The documentation for the procedure should always be described in the body of the report. If the body of the report does not contain something that is mentioned in the heading, then the physician must correct the documentation before it can be reported.

A coder needs the most specific anatomical information, as well as any additional details about the procedure itself. The coder will need to read the entire report for details related to the root operation, the surgical approach, the device, the body part/region, and more.

A coder should not rely on the procedure title itself. A coder must review the entire body of the report looking to answer certain key questions.

Did the physician perform the procedure that they intended?

Did the physician perform any additional procedures?

Were there any complications?

What about the specificity necessary to assign a complete ICD-10- PCS code?

Coders can apply this same process to any operative report they code. Carefully choose the root operation and other code requirements and avoid unnecessary queries.

OP CHECKLIST:

• Was the preoperative and postoperative diagnosis indicated?
• Was the technical procedure described?
• Were there biopsies or specimens removed?
• Was there a description of the findings?
• Were there co-surgeons?
• Was the patient’s condition stated post-operatively?
• Were any operative complications described?
• Was a complaint mentioned?
• Were there any operative scopes used?
• Were specific terms describing the surgery used such as “difficult” or “complicated”?
• Was there general anesthesia or conscious sedation involved?
• Were there extenuating circumstances prolonging the operation?
• How many surgeries were performed during the surgical session?
• Are any of the surgeries bundled into one another, such as the surgical approach and actual surgery?
• How thorough was the operative report in terms of sequencing events and details?
• Are modifiers required?
• Was a history noted?
• Were vitals, an exam, or laboratory tests ordered?
• Were there any added remarks or recommendations regarding the patient or the surgery?
• Was there a decision for immediate surgery indicated (modifier 57 for invasive and 25 for
non-invasive)?
• Does the surgery fall under zero (0) global days such as a non-invasive colonoscopy or a 90 day global package?
• Was this a return to the operating room due to complications from a previous surgery during the post-op?.

CODING FROM AN OPERATIVE REPORT

When you code an open procedure, you need to see the operative report, which includes the following:

The first step in abstracting the billable codes from the medical record of an open procedure is to identify which body part was treated & why. After you have identified that you know which area of the CPT book to check to begin the process of coding.

A preoperative, or preliminary, diagnosis is the diagnosis based on preoperative testing and pertinent physical findings observed by the physician during the examination

The postoperative, or definitive, diagnosis, is what the physician confirmed during the surgery.

Do not code from the outline in the report. These are merely previewing what is to come. For a procedure to be eligible for reimbursement, it must be documented in the body of the report.

A full report containing the surgeon’s description of everything that done during the operation.

The documentation for the procedure should always be described in the body of the report. If the body of the report does not contain something that is mentioned in the heading, then the physician must correct the documentation before it can be reported.

A coder needs the most specific anatomical information, as well as any additional details about the procedure itself. The coder will need to read the entire report for details related to the root operation, the surgical approach, the device, the body part/region, and more.

A coder should not rely on the procedure title itself. A coder must review the entire body of the report looking to answer certain key questions.

Did the physician perform the procedure that they intended?

Did the physician perform any additional procedures?

Were there any complications?

What about the specificity necessary to assign a complete ICD-10- PCS code?

Coders can apply this same process to any operative report they code. Carefully choose the root operation and other code requirements and avoid unnecessary queries.

Helpful Tools

• Having access to the actual operative report, not just a billing sheet where the physician selects the codes.

• Having medical terminology/anatomy experience, or access to the material via diagrams or the internet or a good terminology book

• Having the current year CPT®, ICD‐10, and HCPCS books

• Access to the National Correct Coding Initiative Edits (NCCI) The link there to NCCI Edits (https://www.medicaid.gov/medicaid/program-integrity/ncci/index.html) on the Medicare website. If you’re not familiar with NCCI, this is the National Correct Coding Initiative. This is what Medicare uses as their basis for determining which procedures are bundled with one another; which ones can be billed together; which ones can’t be billed together, and which ones can be billed together if we use a modifier.

• Access to the fee schedules (RVU)

• Diagram or knowledge of surgical positions


The Surgical Package:


1. Local Infiltration, metacarpal/metatarsal/digital block

2. Subsequent to the decision for surgery, one related a e E/M encounter on the date immediately prior to or on the date of the procedure

3. Writing orders

4. Evaluating patient in the Post‐Anesthesia recovery area

5. Immediate post‐operative care

Coding from an Operative Report Standards of Medical/Surgical Practice:

1. Cleansing/shaving/prepping skin

2. Surgical approach, incision, lysis of simple adhesions

3. Insertion and removal of drains, suction devices, dressings, pumps into same site

4. Surgical closure

5. Pre‐op, intra‐op, post‐op documentation (photos, drawings, dictation, transcription)

Coding from an Operative Report The parts of an operative report


The Preoperative Diagnosis

Why is the patient here today? Not necessarily the reason for all the procedures. This is the reason why the patient has now presented for is the “planned procedure.”

The Postoperative Diagnosis

Why were the procedures performed? What was discovered during the operation? Where was the work performed?

The Operation Title of the Procedure

Brief description of what procedures were performed

This should be a total listing, if the item can be coded/billed

Surgeons

Who did the work?

Assistants?

Co‐Assistants?

Co‐Surgeons?

Team?


Anesthesia


Type

General

Regional

Moderate Sedation


Indications


What disease/injury/condition created the need for the surgery?

Is there any indication that there is an existing global period?

Are there indications that this may be a more difficult procedure?


Procedure Note

The procedure clearly outlined

Any complications or misadventures noted

Any unsuspected findings

All unusual findings and additional work

Patient position

Approach

Anatomic site

Depth

Findings

Excisions

Biopsies

Lesions

Foreign Bodies

Anastomoses

Tubes placed drainage/feeding

Hardware used as part of repair

Grafts

Closure(s)

Therapy – line placements

Amount of blood loss

Patient’s status


Surgical Package


Coders need to understand what is included in the general surgical package. These services are not separately billable and include:

Local infiltration, metacarpal, metatarsal, and digital block

Subsequent to the decision for surgery, one related evaluation and management (E/M) encounter on the date immediately prior to or on the date of the procedure

Writing orders

Evaluating patient in the post? anesthesia recovery area

Immediate post? operative care

Note: the following are standards of medical and surgical practice and are not separately billable:

Cleansing, shaving, and/or prepping skin

Surgical approach, incision, and lysis of simple adhesions

Insertion and removal of drains, suction devices, dressings, and pumps into the same site

Surgical closure

Preoperative, intraoperative, postoperative documentation (e.g., photos, drawings, dictation, transcription)

Video Modifiers, Global Surgical Package and Bundled Services Explained
 
We hope this information has been helpful to you on your new medical coding journey & happy you are here at CCO!

Good luck on your exam!

Good luck.png
 
Now you have passed the CPC exam what is the next step?

For many new coders they are designated an apprentice with an A after their credential to notate this designation as a new coder with little or no experience.

CPC exam:
Proof of education or experience isn’t necessary to sit for this exam, but due to the level of expertise required of medical coders, coders must be able to perform not only in an exam setting but also on a real coding job. Those who pass the CPC®, COC™ exams but have not yet met this requirement will be designated as an Apprentice on their credential certificate.

AAPC APPRENTICE STATUS

A CPC designation must have at least two years medical coding experience.

If you have not submitted proof of 2 years of on the job experience, the CPC-A (apprentice) designation will be awarded.

CCO has an Intern program to help remove the A – (Apprentice status) from a credential.

Become a CCO intern.

We invite interns to do coding research in exchange for experience and to be able to put on their resume that they worked for CCO and work toward A removal.

Please note for A removal:

You must have worked a total of 250 trackable hours within 1 year to be eligible for A removal via CCO's Intern program as per AAPC guidelines for A removal.

Please note we have many applicants & only a few intern openings so someone will contact you if you are a consideration for an intern position after filling out the application.

Subject Matter Expert (SME)/Researcher – Intern Position Description

Title: Subject Matter Expert/Researcher

Purpose: Develop content that supports learning objectives for educational products and/or job tasks identified by the bodies of knowledge for certification/CEU products.

Key Responsibilities:
  • Create nuggets for CCO Club and/or courses
  • Demonstrate ability to navigate and use Intern Nugget and Intern Project applications within the Podio Intern workspace
  • Contribute core content and original material by using Pearl Template in Google Drive and provide a completed document based on Google research
  • Supply source materials and provide links for all resources used
  • Provide links to any other quality resources found in the public domain related to given topic that may be shared with students
  • Incorporate appropriate graphics based on research, ensuring that they are based on CCO’s policy on usage rights and creative commons
  • Write multiple-choice review questions to go with completed documents
  • Meet all agreed-upon turnaround time for projects.
Qualifications:
  • Knowledge of medical coding
  • Excellent writing skills and attention to detail
  • Ability to communicate in a professional, concise manner while at the same time providing enough information that will leave few unanswered questions
  • Capacity to see a project through to completion
Time Commitment:
  • The time commitment may vary by project. The scope will be established (and reviewed with the Subject Matter Expert) at the onset of the project

Training/support provided:

Project orientation video
  • Guidance on the development process
  • Conference calls or online development meetings as necessary
Benefits:
  • Opportunity to provide coding research in exchange for experience
  • Ability to improve your resume based on having worked for CCO and by working towards having the “A” removed from your credential
  • Ability to network with other coders and Subject Matter Experts
  • Gain recognition by sharing your skill
Requirements for Removal of Apprentice Designation:

To remove your apprentice designation via on-the-job experience, you must obtain & submit 2 letters of recommendation verifying at least 2 years of on-the-job experience (externships accepted) using the CPT®, ICD-9-CM/ICD-10-CM, or HCPCS Level II code sets. One letter must be on letterhead from your employer*, the other may be from a co-worker. Experience includes time coding for a previous employer and prior to certification. Both letters are required to be signed and will need to outline your coding experience & amount of time in that capacity.

OR:

Submit proof showing completion of at least 80 contact hours of a coding preparation course (not CEUs) AND 1 letter, on letterhead, signed from your employer verifying 1 year of on-the-job experience (externships accepted) using the CPT®, ICD-9-CM/ICD-10-CM, or HCPCS Level II code sets.

Send proof of education in the form of a letter from an instructor on school letterhead stating you have completed 80 or more contact hours, a certificate/diploma stating at least 80 contact hours, or an unofficial school transcript.

  • Completion of the CCO Internship is counted towards the 1 year of experience.
https://www.cco.us/cco-intern-candidate-application/

 
To Maintain a Medical Coding Certification, you will need CEUs:

AAPC Membership is required to be renewed annually and 36 Continuing Education Units (CEU's) must be submitted every two years for verification and authentication of a coders continued expertise.

CEU stands for Continuing Education Unit.

The purpose of medical coding CEUs is to ensure that individuals holding a coding credential remain competent in their area of expertise after they have gained their certification.

The number of CEUs, and type of CEUs one must obtain, depends on the type of credential they hold and the organization through which it was obtained.

Can CEU's Be Used Before Certification?

CEU credits can't be applied until after you have become certified.
As per AAPC: https://www.aapc.com/medical-coding-education/faq.aspx

May I use education completed prior to obtaining my certification? Credit will not be awarded for educational activities completed prior to certification.
If you have a current CCO Club subscription you can re-take any CEU quiz to earn the CEU after you have become certified.


Required CEUs

The number and type of CEUs one must obtain depend on several things, including:

The type of credential(s) held.

The organization one is certified through

The number of credentials held

Obtaining CEUs:

There are several ways to obtain CEUs, but it ultimately depends on the type of credential you hold and the organization through which you obtained it.

CCO CLUB BASIC:

Many CEU opportunities available to earn.

Includes CCO BHAT® for exam manual prep


https://www.cco.us/club/

https://www.cco.us/bhat/

Submitting CEUs:

Once CEUs are obtained they must be submitted according to the guidelines, stipulations, fees, expirations dates, and rules laid out by each organization.

How to Enter the CEU Index Tracker Code on The AAPC Website?

Go to www.aapc.com. There are several ways to get to the CEU Tracker, but one way is to do the following:
  1. On the home page, hover over the Continuing Education on the top (horizontal) navigation bar.
  2. Then, click on CEU Tracker.
  3. Scroll down, if necessary, and click on the ADD CEUs button.
  4. This will bring up a page where you can enter the index number and appropriate date.
  5. Be sure to click SAVE.
  6. Remember to store a copy of your certificate for safekeeping in case of future audits.


Will Your CEUs Work at MAB, PAHCOM or AHIMA?

At this time, CCO is only approved for Core A CEU's belonging to the AAPC. CCO does not pay PAHCOM, AHIMA or other certifying agencies to get our CEUs pre-approved.
However, "AAPC says their CEUs are recognized as the standard in the coding industry, and as such, other credentialing associations (such as AMBA and AHIMA) accept our education with no further review. AHIMA advised CCO that yes you can earn CEUs using units from AAPC. CCO cannot guarantee that any other certifying agency will do this. We suggest that you contact other certifying agencies and ask them whether you can use the CCO Q&A Webinar CEU towards their CEU requirements. Only they have the authority to decide on what CEUs they will accept for their organization.
CCO is a provider of AAPC Core Content Curriculum A CEU's

Core Educational Content
CEUs must be comprised primarily of core educational content (Curriculum A) to show competency. Curriculum A is something that AAPC credentialed members do at the core of their day-to-day practice. As such, APPROVED Curriculum A CEUs must comprise no less than 66% (2/3) of the total CEUs earned per CEU period

Curriculum A
Coding/Billing

  • CPT®
  • ICD-9-CM (Vol. 1-3)
  • ICD-10
  • HCPCS
  • Coding & Billing Policy & Procedure
Clinical
  • Anatomy
  • Physiology
  • Medical Terminology
  • Pharmacy
  • Pathophysiology
Compliance
  • Compliance Auditing
  • Compliance Planning
  • Self Reporting
  • Compliance Training
Regulatory
  • Medicare Regulations
  • Medicaid Regulations
  • OIG Work Plan
  • MS Transmittals
  • Teaching Regulations
  • NCDs/LCDs
Data/Claims
  • Data Management
  • A/R Management
  • Appeals
  • Revenue Cycle
Insurer
  • Payer Contract Negotiations
 
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