Follow the tips below and improving your coding skills will be as easy as 1, 2, 3!
Know the Guidelines: Whether you are assigning ICD, CPT or HCPCS codes the guidelines are your coding bible. If you don’t know the guidelines you likely are not coding as accurately and completely as possible. Your coding will often stand or fall based on the guidelines. When it comes to knowing the guidelines…review, review and more review are key to understanding and application. I recommend making a copy of the guidelines that you can take with you when you’re on the go. Waiting in line at the grocery store, waiting for your child’s soccer game to start or sitting in your doctor’s waiting room (where the magazines are all outdated anyway) are all perfect opportunities to review guidelines. Although you will probably never be able to commit everything to memory, having a thorough familiarity with the guidelines will help you know what coding situations are covered by guidelines and where to find relevant guidance when you need it.
The ICD-10-CM and ICD-10-PCS 2016 coding guidelines can be downloaded at the links below:
ICD-10-CM Official Guidelines for Coding and Reporting
ICD-10-PCS Official Guidelines for Coding and Reporting
Have a Solid Grasp of Pathophysiology: Pathophysiology is the functional change associated with or resulting from disease or injury. As most of us already know, sometimes providers will detail those functional changes within the medical record without specifically documenting a corresponding diagnosis. Having a deep understanding of the changes that come about due to a specific disease or injury helps the coder recognize what condition the provider is essentially but not explicitly documenting, allowing the coder to craft an appropriate query for undocumented diagnoses or diagnostic specificity. Additionally, due to the current trend toward clinical validations audits, where a diagnosis may be coded correctly yet payment may be denied due to lack of clinical support in the medical record for that diagnosis, it is important for coders, clinical documentation improvement specialists and auditors to be even more vigilant in making sure all the pieces of the medical record add up to solidly support the codes that are reported as the basis for reimbursement calculation.
Sharpen Your Research Skills: Now, even with the guidelines committed to memory and an exceptional knowledge of pathophysiology, the ever changing landscape of medicine (Can you say ICD-10 implementation) will insure that even the best coders will often run across coding situations where they do not have enough coding or clinical knowledge to code something completely and/or accurately. This is why being a good researcher is critical to being a good coder. You must know how to find appropriate and helpful information in order to tackle complex coding questions or to support your coding decisions when official guidance is not to be found.
Official sources include:
• ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting
• CPT Coding Guidelines
• AHA Coding Clinic
• AMA CPT Assistant
Other helpful resources include:
• Medical dictionary
• Pharmacology drug reference
• Merck Manual
• Professional association (AAPC, AHIMA) publications
• Medical specialty publications
• Regulatory agency guidance (LCD/NCD)
The internet makes it quick and easy to find information. However, exercise some amount of caution if making coding decisions based on information you find online. Unless you are working from the website of an official source such as AHA, AHIMA, AAPC, CMS, etc. take the time to make sure the source is valid.
It may take some time to implement all of the tips above, but the time invested will pay dividends in code assignment that is more complete, correct and ultimately more compliant.