Medical Coding Tips — Coding Surgical Procedure
Medical Coding Tips — Coding Surgical Procedure http://www.cco.us/cco-yt
This one is kind of a brief one.
Q: Coding Surgical Procedure – I was wondering if someone could give me a few tips on how to figure out the wording when coding a surgical procedure? I have the study guide but the questions that they ask without the multiple answers are where I don’t know what to look for. I really appreciate any help you may have. Thanks, Mary.
A: When you take a coding course, you typically start off with a few words, like, Ebola and you go look it up in the index. Then you start building on that. You might get a little scenario, a little blip, and then you get real report, the kind of code. A lot of times, especially with our CPC Review Blitz, we are focused on helping you pass the exam, so we do focus on multiple choice. But it does relate to the real world, in that you will go to the index, if you have a term, and it will often give you a range of codes. It doesn’t just give you one, sometimes. But for the most part, you go and you consult a range of codes and you look at those codes and you compare them and you contrast them and you see which one best fits your documentation. So, multiple choice training isn’t necessarily a bad thing. So, now you’re saying, “Woo! Now I’m out on the real world and no multiple choices. Where do I start?”
So, I’m just going to take a quick report that I Googled earlier. This is what first came up, it could be any report. Apparently, this is a sample where they’re trying to help their physician know an acceptable operative report is. Physician education, coders get involved in it.
This is a typical layout. We got the patient’s name and address — their demographics – their name, the date. This is where you want to start, you don’t want to just code here. But these three things: preoperative, postoperative, and procedure – these are the diagnostic and procedural statements that you will be starting your coding from. So, I believe the question was focused more on the procedure, so I’ll focus on that.
So, here’s the statement – and don’t get excited. The doctors don’t give you CPT code. It just happened to be on the sample – bilateral upper lid blepharoplasty, so they’re getting an eyelid job. What you would do as a coder, you don’t read the whole report, not yet. You go and you start with the statement, because this is what Dr. John Good said he did. So, you go to the index and you look up probably “blepharoplasty, upper lid” and you come up with your code and you might find that there’s one or two, or maybe three different types of blepharoplasty codes. If you don’t have enough in this statement to pick one, then you go and you read the body of the report. They call it abstracting, you’re abstracting the info that you need to get the correct code.
Now, you do read the op report to see if there’s anything extra that the physician did that you should code also. Where your skill comes in, as you start to learn things, like, an oophorectomy (removing an ovary); then, you see “Oh, they did a laparotomy. I should code that.” But what you learned in coding is – no, you don’t code the approach, you don’t code the path to get there. So they opened the abdomen, “laparo,” right? And to get to the ovary, you remove it, the oophorectomy; then, you don’t code the laparotomy. It’s bundled in. As you’re reading the story, that’s what you’re skimming for, just coding some extra stuff. If you find that, then you go ahead and code it.
Now, you could go ahead and code it and then maybe pop it into a CCI checker, which that’s the Correct Coding Initiative. It’s where they basically tell you if the Medicare considers the two codes bundled, where one is bundled into the other. And that’s how you learn. So, this is actually what we do in our practicum course, we use Practicode as the background for the course and you code live cases like this. You log in as if you’re a remote coder, and on the left-hand side you’ve got your note and your demographics on the top, they’re made up of course because it’s practice. And then on the right-hand side, you’ve got a box to pop-in your diagnosis codes and your procedure codes. Then, you hit submit.
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