One
of the things I love about the mentoring I do for coding students is it reminds
me of what it was like to be a newbie. And I don’t just mean the excitement of
being on the cusp of a new coding career. I am also grateful to be humbled and
reminded that I knew absolutely nothing when I got started. These days, when I
stand in front of an audience of coders or coding students and teach the latest
and greatest on whatever topic I’m discussing for that day, it’s the
culmination of years of experience and hours (or weeks) of research and
preparation. But you might be interested to know that in my first coding job, I
did come home from work on more than one occasion in
tears.
Reality Sets In Quick
I can’t explain that helpless feeling when you’ve
trained so hard — and studied and taken numerous tests and graduated, etc. etc.
etc. — and you land that first job, and they hand you an operative report. And
you freeze. Because it’s like Greek. You have no idea what to do. Where are the
short coding scenarios you learned in school? What does that first paragraph
really say? You know you could find the code if you could just figure out what
the heck the darn report says (incidentally, I now consider myself trilingual:
English, medical terminology, and coding!). You know you’re qualified, but are
you really?
You know you could find the
code if you could just figure out what the heck the darn report says
(incidentally, I now consider myself trilingual: English, medical terminology,
and coding!).
So I sometimes forget when
I’m working with new students what it was like. Of course, there are still days
when I feel like crying because I keep getting myself into uncharted territory.
I actually relish researching and “figuring out” things that other people may
abandon because they are too foreign or “difficult.” But it wasn’t always that
way. I used to be an overconfident, novice coder who, when a chart was placed
in front of her, did a lot of tap dancing to make it look like she was
competent. The good news is, 15 years later, I feel competent (most of the time
anyway!).
The Word
Search
I’ve worked in
coding education now for about eight years. In that time, I’ve been asked to
work on a lot of different projects related to coding education. In addition to
training coders, I’ve been asked to evaluate people to see if they would make
good coders. And I always start with the word search test. Do you like word
searches? If not, you might want to consider a different career. Because coding
is one big word search. You have to decipher the medical record (or operative
report) and decide which words are important and which ones you can ditch.
Bunionectomies
are a Kick
The first time I was given a
bunionectomy report to code, I’m pretty
sure I cried. After all, the procedure title was something like “Mitchell-Chevron,”
which meant nothing to me. And I knew enough about coding to know I had to read
the report to figure out if it really was a Mitchell-Chevron. And the report
was surely about four pages — pretty standard for a thorough podiatrist. And
when I went to a class to learn how to code bunionectomy procedures, I realized
that out of the entire four pages, I focused on about three sentences. That was
it. The rest was coding garbage. In case you’re wondering, a Mitchell-Chevron
bunionectomy involves removing the medial eminence (bunion) and making an
osteotomy (bone cut) into the first metatarsal (the foot bone connected to the
big toe). I’m still amazed that it takes four pages to describe that.
Deciphering
the Operative Report
I am often asked to explain
how to decipher an operative report. Well, it depends on the procedure, really.
And if you are a new coder and you ever have the opportunity to go to a seminar
where they will present case studies, this is the best way to learn. I’ve
taught dozens of classes and nothing drives home my point more than walking
through the cases and coding them. But I will give you some basic elements here
to get you started. While these rules don’t apply to all specialties (e.g.,
interventional radiology has “special” rules that drive the even the most
experienced coders — that would be me — batty!), this should get you started on
some of those basic surgical reports:
Rule 1 – Doctors Lie: Admit it, you watch House
and have heard him say on more than one occasion that patients
lie. Well, Dr. House, I would like to point out that doctors lie, too. They
will state the procedure one way in the title and then proceed to describe a
completely different procedure in the body of the report. For example, the
doctor may state a left heart catheterization was done, but after reviewing the
report, the catheter never made it all the way to the heart — only to the
coronary arteries. So keeping this in mind, you should never believe what you
read in the procedure title. Honestly, I rarely even read the procedure title
anymore — it’s often fiction. As for Dr. House, I would love to see a
strong-willed coder have it out with him on the show about his documentation,
which I’m sure is a mess.|
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Rule 2 – Get a Medical
Dictionary: There’s no excuse anymore. When I learned how to code,
we were still
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using
Windows 3.1, so there was no way the hospital was using the internet. But even
without online resources, I had a medical dictionary on my shelf. And it was used
often. How will you know if something is important if you don’t even know what
it means? While you’re at it, make sure you also have access to an English
dictionary. I know it’s a novelty, but you will also find complex nonmedical
words in the operative report (or even in your code descriptions). If you don’t
know what it means, look it up. Tedious, I know, but you will learn. Of course,
you might feel like Billie Dawn from Born
Yesterday, but you will learn. (Don’t understand the movie reference? Look
it up!).
Rule 3 – Just Like Ragu, It’s
Probably in There:In school, we hear terms
like “it’s bundled” or “separate procedure,” but what does that
really mean? Well, it means it’s integral to the main procedure and don’t code
it out separate. What’s included? Well, pretty much anything that has to be
done in order to accomplish the main procedure. Taking out an appendix? Well,
then the incision (or creation of ports for laparascopic instruments) is
included. So is the closure at the end of the procedure. I don’t know about
you, but if I have my appendix taken out, I sure hope the physician remembers
to suture me closed at the end. All those things are like regular ingredients
in Ragu pasta sauce: tomatoes, oregano, garlic. It’s in there! So don’t code
each component out separately. Now, had they decided to do a liver biopsy while
in there, that’s different. That’s like throwing a banana in the pasta sauce.
So it gets coded separately.
Rule 4 – You Will Only Use 10-20%
of the Operative Report: Don’t feel like you need to use every word in the operative report to
code the case. The fact is, the operative report isn’t about you, it’s about the patient, and it’s a communication tool for clinicians. It just
happens to double nicely as a recording of everything that happened to the
patient and can substantiate coding and billing. It’s up to you to determine
what’s important in the documentation. There’s a reason we use coding for
billing: Your codes actually fit on a one-page claim form so the insurance
company doesn’t have to read through every single medical record. Rule 5 –
Know the Procedure: Okay, maybe I should have led off with that one. Medical terminology is, quite
literally, a foreign language. In fact, it’s at least two foreign languages:
Latin and Greek. So when you say “it’s Greek to me,” you’re being quite
literal. A really good medical terminology class will solve a lot of problems.
You may think esophagogastroduodenoscopy is a really big word until you break
it down and realize it’s visualization (scopy) of the esophagus (esophago),
stomach (gastric), and part of the small intestine (duodeno). You also need to
know your anatomy. You need to know when they operate on a structure that’s
part of a bigger structure (e.g., mesentary of the intestines)
vs. a different organ altogether (like in the appendix/liver example above).
After you learn medical terminology and anatomy and physiology, that’s half the battle. The
rest of the battle can typically
be solved with Google. Come
to think of it, there are few things that can’t be solved with Google. I’m
pretty sure there will be a support group some day for Google-aholics, but in
the mean time, I highly encourage you to google a procedure if you don’t know
what it is. I never remember what a Whipple procedure is. But I can google it
in about 10 seconds. Just be careful which website you select from your Google
search list — something from the Mayo Clinic is probably more reliable than
lazy-Dan-explains-medical-procedures.com.
Rule 6 – There is Crying in Coding, Just Don’t
Let Anyone See It: Oh,
how I wish I could tell you I had that one down. But I’m pretty
transparent when it comes to being frustrated. And I’ve had students cry in
frustration when trying to code case studies. But try to minimize your public displays of tearful frustration and
remember this: We’ve all been there and this is hard. It’s
okay to not know all the answers all the time.
I hope this at least gets you moving in the
right direction. When people ask me how I learned everything I know I, 1)
laugh, because I know there is so much more for me to learn, and 2) tell them
how the rules above worked for me.
This article is reposted
from Kristi Pollard’s blog Coder Coach, with permission.
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