There can be confusion on how to report lateral- LT/RT and bilateral modifiers-50.

Coders report many of these incorrect or miss reporting altogether.

There is a false impression that medical coders sit in their pajamas all day while entering codes consisting of letters and numbers.

Here is what a coder’s job truly consists of in no particular order:

What is the difference? We'll tell you! 

When looking for a job in the medical coding world, there is often some confusion between facility coding and professional coding.  The main difference is that professional coding is mandated by CMS and facility coding is facility based.  In this article, we are going to focus on the difference in the emergency room setting.

Can a medical coder fulfill the role of an inpatient CDI?  Yes, a seasoned, credentialed coder can. 

A seasoned, credentialed coder has the skills necessary to see the story of a patient.  These high-level coders investigate, analyze and problem solve.  These are not just people who apply codes- they take ownership of the record. 

HCCS’s Coding Canapés: Tasty tidbits of coding delivered directly to your desktop!

One of the best (and maybe worst) things about the coding profession is that there is always so much more to learn. The infinite nuances of various continuously changing coding guidelines combined with the wildcard variable of documentation, and evolving HIM technology give us no choice but to take the “never stop learning” philosophy especially seriously. Whether you are one of our coders or not, HCCS is here to help you in your pursuit of knowledge as you grow in your career. Through the Coding Canapés series of posts, we’ll regularly introduce and interpret official guidelines such as AHA’s Coding Clinic. We hope coders everywhere benefit from and even enjoy these posts. Bon Appétit!

Coding cervical disc disorder with myelopathy involving different levels.

Outpatient coders for physician offices, clinics in the hospital setting, or ER coders may see a similar situation such as this one with cervical disc disorders.  If there are different levels, how do I know which level to code?  Is it the highest level or all the levels?  See the coding clinic to determine the correct code.

A patient is diagnosed with cervical disc disorder with myelopathy involving different levels.  How do I code this?

HCCS’s Coding Canapés: Tasty tidbits of coding delivered directly to your desktop!

One of the best (and maybe worst) things about the coding profession is that there is always so much more to learn. The infinite nuances of various continuously changing coding guidelines combined with the wildcard variable of documentation, and evolving HIM technology give us no choice but to take the “never stop learning” philosophy especially seriously. Whether you are one of our coders or not, HCCS is here to help you in your pursuit of knowledge as you grow in your career. Through the Coding Canapés series of posts, we’ll regularly introduce and interpret official guidelines such as AHA’s Coding Clinic. We hope coders everywhere benefit from and even enjoy these posts. Bon Appétit!

Respiratory failure following a drug overdose, sequela or a manifestation?

Inpatient or observation coders for acute hospital settings may see a similar situation such as this one with chronic respiratory failure following drug overdose.  How do I know if it is a sequela or a manifestation?  Coders may find it difficult to know whether to follow the poisoning guidelines or not.  See the clarification from the coding clinic to determine the correct path.

Feeling frustrated about that coding assessment for a potential new job? We understand. Let us explain the importance of the exam and how it can benefit you.

Recently I came across several LinkedIn posts discussing coders disappointments towards coding tests used during the screening process.  This frustration caught my attention and while I can sympathize, let me take a moment to give you some background on why companies need to have a coding assessment in place.

You just landed your first medical coding job. Congrats! Next step, organize your desk and office space for success. Read how our experts get organized.

You did it! You just landed your first medical coding job so now you start clearing the dining table, place your laptop down and start your new journey. That's all there is to it, right?

Think again! Let me introduce you to your new friend: HIPAA. It is the governing regulation that maintains patient privacy and integrity.  It will also shape the way you setup your office.

HCCS’s Coding Canapés: Tasty tidbits of coding delivered directly to your desktop!

 One of the best (and maybe worst) things about the coding profession is that there is always so much more to learn. The infinite nuances of various continuously changing coding guidelines combined with the wildcard variable of documentation, and evolving HIM technology give us no choice but to take the “never stop learning” philosophy especially seriously. Whether you are one of our coders or not, HCCS is here to help you in your pursuit of knowledge as you grow in your career. Through the Coding Canapés series of posts, we’ll regularly introduce and interpret official guidelines such as AHA’s Coding Clinic. We hope coders everywhere benefit from and even enjoy these posts. Bon Appétit!

Topic

What is perinatal period in ICD-10-CM? Is the administration of Pitocin to augment active labor coded separately in ICD-10-PCS?

ICD-10-CM-

 Question  

The Official ICD-10-CM Guidelines for Coding and Reporting in the chapter on the perinatal period state, “For coding and reporting purposes the perinatal period is defined as before birth through the 28th day following birth.” Therefore, does this mean that the perinatal period ends on the 29th day of life, making the day of birth equal 0 days?

HCCS’s Coding Canapés: Tasty tidbits of coding delivered directly to your desktop!

 One of the best (and maybe worst) things about the coding profession is that there is always so much more to learn. The infinite nuances of various continuously changing coding guidelines combined with the wildcard variable of documentation, and evolving HIM technology give us no choice but to take the “never stop learning” philosophy especially seriously. Whether you are one of our coders or not, HCCS is here to help you in your pursuit of knowledge as you grow in your career. Through the Coding Canapés series of posts, we’ll regularly introduce and interpret official guidelines such as AHA’s Coding Clinic. We hope coders everywhere benefit from and even enjoy these posts. Bon Appétit!

The Topic:

Heart Failure with Preserved Ejection Fraction and Heart Failure with Reduced Ejection Fraction

ICD-10-CM-

Question

Please reconsider the advice previously published in Coding Clinic, First Quarter 2014, page 25, stating that the coder cannot assume either diastolic or systolic failure or a combination of both, based on documentation of heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF). Would it be appropriate to code diastolic or systolic heart failure when the provider documents HFpEF or HFrEF?