Silly Question

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Vivi in Monroe, North Carolina

62 months ago

In what stage of the patient's course of care do medical coders, code for them? I mean, do the coders code for every time the patient visits the doctor's office and for every day the patient stays in the hospital? Or do the coders only code when the patients been discharged? Or does it vary. Confused, please help.

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valentine2 in salt lake city, Utah

62 months ago

Vivi in Monroe, North Carolina said: In what stage of the patient's course of care do medical coders, code for them? I mean, do the coders code for every time the patient visits the doctor's office and for every day the patient stays in the hospital? Or do the coders only code when the patients been discharged? Or does it vary. Confused, please help.

It might vary per organization, but most clinics code out patient visits right away, most clinics track lag time from when the patient was seen, to when the charges were entered to when they receive patient from insurance. So it is important to get in charges right away.

For inpatient hospitals, everywhere I have worked, the charges were not put in until the patient was discharged. Patients often get bounced around, so it can get confusing, so its easier if one person just puts in all charges for the patients stay.

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Vivi in Monroe, North Carolina

62 months ago

That helps so much. Thanks!

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valentine2 in salt lake city, Utah

62 months ago

Vivi in Monroe, North Carolina said: That helps so much. Thanks!

Sure thing, and as they say, there are no silly questions

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Vivi in Monroe, North Carolina

62 months ago

I guess not, but they probably seem silly to people who are actually in the office coding and are not just learning from class. I have a few more obvious questions. How do you query the physician? Do you call him? email him? Is there some sort of form? Also, I've read that you're supposed to send in a special report with the use of certain codes and modifiers. Do the coders write the reports or the doctor? If a doctor writes it, how will he know to write one without the coder having assigned a code already? Thanks in advance.

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valentine in Layton, Utah

62 months ago

Vivi in Monroe, North Carolina said: I guess not, but they probably seem silly to people who are actually in the office coding and are not just learning from class. I have a few more obvious questions. How do you query the physician? Do you call him? email him? Is there some sort of form? Also, I've read that you're supposed to send in a special report with the use of certain codes and modifiers. Do the coders write the reports or the doctor? If a doctor writes it, how will he know to write one without the coder having assigned a code already? Thanks in advance.

Again, it varies per office, but more importantly, it varies on organization size. When I first started out at a very small eye clinic, we would just walk up and ask the physicians if we had a question.

The next place I worked at we emailed the physicians, and now, in our EMR system, we have a place to request additional information from the providers.

To your next question, as a coder, I have not had any personal experience with the special notes that must be sent. That is done usually on the billing side, and in my experience, after the codes were already sent to the insurance, and the claim was denied for further documentation, which the billers would query the phsyician on.

However, I have had a few physicians who had patients that were having ongoing treatment which required extra documentation, we knew ahead of time and we would send it, but seperately since they claims go electronically and they would mail the additional information to the insurance. Does that make sense? I realize I often talk in circiles lol

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Viviel in Monroe, North Carolina

62 months ago

Thanks that does make sense. Sorry that it took so long to reply. I was on winter break. You're really helpful. Are you a certified coder? How long have you been coding?

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valentine2 in salt lake city, Utah

62 months ago

Viviel in Monroe, North Carolina said: Thanks that does make sense. Sorry that it took so long to reply. I was on winter break. You're really helpful. Are you a certified coder? How long have you been coding?

no worries, just glad you got the information you needed, I realize I can be confusing.

yes, I am CPC certified and have been coding for 6 years.

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Viviel in Monroe, North Carolina

62 months ago

I'm studying the Icd-9-cm guidelines and in Section IV it says:

"The Uniform Hospital Data Discharge Set (UHDDS)defintion of principal diagnosis applies only to inpatients in acute, short-term, long-term care and psychiatirc hospitals."

From what I've learned so far, the term principal diagnosis applies to all inpatients. I checked Section II of the guidelines and it says:

"...the application of the UHDDS defintions has been expanded to include all non-outpatient settings(acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc)."

These two sentences seem contradictory. Is this a mistake in the guidelines or am just I not seeing something?

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valentine2 in salt lake city, Utah

62 months ago

I am not a facility (inpatient) coder, but rather an outpatient coder, so I am not real familiar with this particular guideline, but I found this online:

"Principal diagnosis is defined as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."

Since hospital stays, rehab, pysch, etc. all dates of service are coded after the patient has completed their treatment (ranging from a couple of days to even a couple of months), usually one person codes out their entire stay, using the same primary diagnosis code throughout all dates of service.

So yes, this applies to non outpatient settings.

I am not entirely sure what you are asking, so if I didn't answer your question, let me know.

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Viviel in Monroe, North Carolina

62 months ago

I understand what the principal diagnosis is, but I'm not sure to what it applies. You said it applies to non-outpatient settings. Does this mean all non-outpatient setting or only some?

"The Uniform Hospital Data Discharge Set (UHDDS)defintion of principal diagnosis applies only to inpatients in acute, short-term, long-term care and psychiatirc hospitals."

This sentence seems to limit the definiton of principal diagnosis to only certain inpatients. It makes it seem like the term principal diagnosis applies only to acute, short-term, long-term care and psychiatric hospital inpatients and not to other types of inpatient.

My problem is that a previous guideline (Section II) says the defintion has been expanded to includes all non-outpatient settings.

So does principal diagnosis apply to all inpatient or only some?

You said you focus mainly on outpatient so I'm going to try the inpatient forum also. Thanks for your help.

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valentine2 in salt lake city, Utah

62 months ago

Sorry to not be of more help. Posting it in the inpatient forum will probably give you the answer you are looking for.

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Viviel in Monroe, North Carolina

61 months ago

I have an outpatient question.
If a patient presents for outpatient surgery but the surgery isn't performed due to a contraindication, I'd code the reason for the surgery as first-listed followed by code V64.1, "procedure not carried out due to contraindication". Would I also code the contraindications or is that unneccessary?

Thanks for all your help.

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Viviel in Monroe, North Carolina

61 months ago

This for all the coders out there.
I'm learning how to code and I notice that many rules vary depending on the insurance company. Do medical coders have to become familiar with the different insurance company rules? Like when coding E/M service levels, some third pary payers require different number of elements for a service to be considered problem focused or detailed. Do coders just stick to the Medicare guidelines and hope the claim isn't audited or is there something else? Thanks for your help.

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valentine2 in salt lake city, Utah

61 months ago

I must admit, I have never heard of an insurance company requiring different number of elements, unless you mean some go off the 1995 E/M guidelines, while others go off 1997?

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Vivi in Monroe, North Carolina

61 months ago

That's what I was confused about. My book said some insurance companies have established their own requirements. For example some companies may require a review of 3 PFSH instead of 2 to qualify for the comprehensive level. Its confusing to think I'd have to consider different requirements. Would it be safe to assume that most companies follow either the 1995 or 1997 guidelines? Is that what you do? Since you never heard of this confusing rule, I'm not going to worry to much about it.

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valentine2 in salt lake city, Utah

61 months ago

Vivi in Monroe, North Carolina said: That's what I was confused about. My book said some insurance companies have established their own requirements. For example some companies may require a review of 3 PFSH instead of 2 to qualify for the comprehensive level. Its confusing to think I'd have to consider different requirements. Would it be safe to assume that most companies follow either the 1995 or 1997 guidelines? Is that what you do? Since you never heard of this confusing rule, I'm not going to worry to much about it.

I have never heard of this rule. As coders we code according to the AMA's 1995 or 1997 guidelines. We are not to code to conform to insurance rules or for reimbursement being the main concern.

Each organization is allowed to choose between 95 or 97, whichever is more advantageous. The providers I code for, their dictation template is set up so I pretty much only use 95, but I occasionally use 97.

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Vivi in Monroe, North Carolina

61 months ago

Oh, I get it. At least I think I do. The insurance companies rules are not a coder's concern. We just code according to CMS and AMA rules and the billers do the rest, right?

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valentine2 in salt lake city, Utah

61 months ago

Its not that their rules aren't a concern, but rather we are supposed to code according to what was done, not by what will get paid. This is a concern in most organizations, where coders are told to change codes "so it will get paid" even if they are not the correct codes.

Another common practice is putting modifiers on.
I can't tell you how many times a biller would tell me "the insurance says they'll pay if we add a modifier" even though a modifier was not appropriate.

Its kinda like tug of war when it comes to billing and coding, obviously the physician needs to get paid, medicine is a business, but as a coder, our main concern is accurate and correct coding, rather than adding codes just so they doctor gets paid.

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Vivi in Monroe, North Carolina

61 months ago

valentine2 in salt lake city, Utah said: Its not that their rules aren't a concern, but rather we are supposed to code according to what was done, not by what will get paid.

So the coders don't code any differently depending on the insurance company. They follow coding rules first and then do what it takes to get the claim paid if they can. But coding rules come first. Right?

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valentine2 in salt lake city, Utah

61 months ago

Vivi in Monroe, North Carolina said: So the coders don't code any differently depending on the insurance company. They follow coding rules first and then do what it takes to get the claim paid if they can. But coding rules come first. Right?

the exceptions are of course medicare and medicaid, they have their own rules. So yes, we use different codes sometimes for patients with those insurances.

But mostly yes, (especially when it comes to E/M) we code according to AMA guidelines, not what an insurance company wants.

If the insurance company is denying, the claim is usually reviewed to find out if it was coded correctly, if it wasn't (and there is documentation to support the changes) then a corrected claim is sent.

But if the claim is correct, an appeal is sent ( I believe up to 3 appeals can be sent) but sometimes, the insurance refuses to pay for something (even though it is correct) and is written off or becomes patient responsiblity (depends on patient insurance plan and coverage)

Probably way more than you wanted to know lol

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Vivi in Monroe, North Carolina

61 months ago

No, that was exactly what I wanted to know. Thanks so much. My mind is clearer with that straightened out.

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Vivi in Monroe, North Carolina

61 months ago

Does anyone know what a cc exclusion is? They're in my ICD-9-CM book, but it doesn't explain what they are? Thanks.

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Vivi in Monroe, North Carolina

60 months ago

If a patient has mononucleosis with dehydration, you'd only code the mononucleosis right? I think my book made a mistake.It says to code for both mononucleosis and dehydration.

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