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Medical Coding Help!! - codernc

Posted: May 14, 2014

I am currently enrolled in coding and scheduled for my CPC exam next month. I am so confused with all of it!! I really don't understand what you are supposed to code exactly from a note? Do you code everything, pmh, social history, procedures, impression, diagnoses? This is the hardest part for me, is knowing exactly what I am supposed to code. I had thought that it was just mainly the procedures and the disagnoses or impression, but sometimes it seems to be things listed in the whole report, like everything that is wrong with the patient, any history of any problem, etc. This is so confusing to me! Any advice would be greatly appreciated!

Also, any advice for taking the CPC would be greatly appreciated, as I am sure as confused as I am right now, I will not do well at all on it.

Thanks

this has been my biggest question too... - coding student

[ In Reply To ..]
What program are you taking, if you don't mind my asking? I'm in a self-instructed course that isn't going very well. I wonder if this question is better addressed in more of a traditional classroom setting.

I am taking the Andrews course.. What about you? - codernc

[ In Reply To ..]
I am just really struggling with it... I often wondered if an actual class setting would be better.

I know what you mean.... - sm

[ In Reply To ..]
I'm enrolled but probably dropping out of Coding for HCP, online course. I'm about halfway through the book but having the exact same problem you are. I keep reading and re-reading the same chapters and wondering why can't I grasp this??

Reading and rereading - sm

[ In Reply To ..]
You can't grasp this until you have a reason to use the information. When you need to know it, it will begin to make sense. Just reading and rereading won't help much.

Instead of reading and rereading, try coding the exercises and looking up wat you need when you need it. You will get a whoe lot more out of it.

Therein lies the problem... - sm

[ In Reply To ..]
I get the practice exercises right, but that's just where they give you a diagnosis and you code it, but then the test questions lay out a whole story of symptoms and multiple diagnoses and I'm supposed to figure out what to code. Im usually only getting about 50-75% correct since there are no practice questions that prepare me for that. It's maddening.

Guidelines - My 2 cents

[ In Reply To ..]
In your coding books (ICD-9 and CPT) at the beginning of the books there are guidelines governing what and what not to code. In an outpatient setting, you cannot code "probable" diagnosis, it has to be confirmed and you need to show documentation; you need to look at the reason for the patient's visit. In an inpatient setting, look at all the problems, procedures performed, lab work, etc., etc. Remember that you are looking for billable items. In the workplace, you are going to have to go through the entire patient record and figure things out. It's very important that you know the coding guidelines, I'm surprised your class has not addressed that more thoroughly before they had you code a chart.

Wondering if you are an MT and skipped - the A&P and Pathophysiology?

[ In Reply To ..]
I'm wondering if you went with the option that lets you skip pathophysiology and A&P. That could explain a lot of the problem. If you don't have that knowledge, it can be very difficult to understand what to code. Sure, it is easy to just parrot the list of diagnoses into codes, but it is more complicated to use your own knowledge to sort out everything else.

If that is the case, you can do outpatient coding more easily. It isn't as involved.

outpatient - versus hospital coding

[ In Reply To ..]
I code outpatient for a multispecialty clinic and have been instructed to code not only the impression but chronic conditions as well. I also code labs and radiology if the patient had those. So outpatient can be involved, maybe not as involved.

I, too, went there and suggested a while back it would help to have "sample videos" and wa - graduated

[ In Reply To ..]
I still think it's an awesome school, but I also think some sample videos would have been nice. I watched some sample Coding Blitz videos and it helped a lot. Coding is a tricky to learn, and there were times I questioned my intelligence and also my reading comprehension when reading through the course books. The only thing I would say is ask questions! I didn't ask too many questions because I was afraid they would think I was dumb and not cut out for coding, but that's what the instructor is there for. I hope things become more clear for you. It takes a while, but you will get it.

My take on "ask questions".... - Why....

[ In Reply To ..]
It is my opinion that the instructors at Andrews would receive the SAME questions from SEVERAL students, as we are all learning the same guidelines. It would be hugely beneficial for Andrews to have a guidelines FAQ for their students. This program has been successful for many years... By now the instructors KNOW the areas that the students have struggled with. I never could understand why they prefer to answer similar question after question. The online format is not conducive to that as it takes several days to get the answers and some students move from module to module quickly. And please do not tell me its because they want us to know how to formulate a query and/or derive at the answers on our own. :)

I went there but did fine with the course - Everyone is different

[ In Reply To ..]
The CPC is outpatient and the questions are multiple choice. As I recall, there were few, if any, long notes.

They will give you code choices. Don't code it and then look to see which answer matches -- you will never finish. Instead, read the question and eliminate answers that contain obvious wrong codes. That will leave you with maybe 2 choices. Just look up the codes and choose the answer that is the most correct.

To answer your question somewhat, there are loads of things in notes that we don't code. Whether inpatient or outpatient, code only what is relevant to that stay.

Depends on the type of note - - why the pt is there.

[ In Reply To ..]
Is it an office note? Patient came in for something, what is the final dx? The main reason for visit would be the primary diagnosis, and pick up any chronic conditions that the physician is checking on, prescribing meds for. OP notes, what is the reason for the procedure? That is the main diagnosis and same thing, pick up chronic conditions that affect care.

Where, exactly, are you in the course??? - sm

[ In Reply To ..]
I wonder if you aren't getting confused with inpatient materials.

The CPC is OUTPATIENT coding. Code the reason the patient is there. In other words, what did the doctor address or treat? What did he do to treat it?

No, a classroom setting is not much different. You would be hard put to find one, in any event. Coding is just not easy to learn.

You are not alone - MT2Coder

[ In Reply To ..]

I am in the second Module and have the same problem. I do excellent on the actual quizzes but not well on the end of the chapter review exercises with the indepth scenarios. Just glad to now know it is not just me.

Glad to know I am not the only one having issues with it - Codernc

[ In Reply To ..]
I am hoping it will all click one day! I don't understand how you can code I guess for more than what the doctor puts down as the diagnoses or impression. I think that is a lot of what I having issues with. Don't the code have to go beside what they have down as a diagnoses? Also is ER considered outpatient? I know these probably sound like stupid questions but I feel so lost!

If you feel so lost ... - Wondering

[ In Reply To ..]
If you feel so lost, why have you not asked your instructors these questions??? That is what you are paying for! Your instructors are perfectly well able to answer these questions.

Yes, ER is outpatient. Everything that is not an "inpatient admission," where the patient stays in the hospital and is formally "admitted" is outpatient. Ambulatory care in hospitals is outpatient, even though it is in hospitals, because the patient is not admitted. Outpatient imaging, lab, clinics, PT clinics, ER and ambulatory surgery, etc., are outpatient. This does not mean the patient is in a bed, either. Observation stays are in a bed, but they are outpatient because the patient is not admitted.

What concern is underlying your feeling that you can only code the diagnoses or impression? The doctor is responsible for everything in the note. If he signed it, he takes ownership of it. He does not know how you work or what you need, so he is not thinking about you when he makes that list. He is just documenting for patient care. You can use everything he writes.

Why don't you post one of these difficult questions with its answers. We can chime in with explanations.

I am going to send Linda a bill for this. Maybe she'll hire me!

coding - zoesmom04

[ In Reply To ..]
I'm in a coding certification program at a local university. My instructor constantly reminds us to be familiar with the guidelines in your CPT manual. Also, if the chart states 'rule out' or 'probable' diagnosis--do not code. Like the earlier post stated, it has to be a documentable diagnosis before coding. Lab work, tests, procedures are all documentable. The evaluation and management section of CPT will tell you exactly what are outpatient facilities and whether it is an outpatient vs. inpatient visit. Then there's modifiers that you have to familiarize yourself with.

I would be lost without face-to-face instruction before attempting certification, although I've heard of the exceptional cases where some buy coding manuals, reading and passing.

Best wishes

And then there is inpatient coding ... - where the guidelines are different.

[ In Reply To ..]
Your course sounds as though it is outpatient-only? The OPs seem to be in an inpatient/outpatient course and talking about diagnoses, not procedures. Inpatient coding uses different guidelines. Rule-out and probable diagnoses are coded, and you cannot pick up diagnoses from lab and x-rays, for instance, unless the attending does.

why newbies aren't asking instructors ?s - pondering2codefrmMinn

[ In Reply To ..]
I think the earlier comment rings true for many that have undertaken the online coding instruction. So many seasoned coders come on here to admonish new students that have not yet begun to understand the subject completely. They appear to need an 'anonymous' forum to vet out answers and reach out for direction lest they look like they are not competent from their instructors. In today's world, assistance can come from many, informed sources which will eventually make these new ppl excellent coding professionals. Good luck to everyone!

Fear of an instructor thinking you are not - competent???

[ In Reply To ..]
We can understand that some students make unfortunate choices in choosing schools that do not have instructors at all. However, on this board, we usually answer questions regardless. We are happy to advise no matter what.

In this case, though, one school mentioned (Andrews) has highly qualified instructors, as well as other resources they can draw upon, capable of providing intense personal instruction. They have an excellent track record on certification exams to demonstrate that their system works. To my knowledge, their grading is objective, so an instructor's opinion of you doesn't matter.

Frankly, failing to use the resources provided for you is a waste of time and money. Hiding a problem like that is self-defeating and pointless.

No one was saying the students should not ask here. We just encouraged the students -- well, one of them, the other is in an instructorless course, sadly -- to use their school's resources, as well.

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