Find Your Routine: Take Advantage of Educational Opportunities
When it comes to coding and documentation, finding your own rhythm can lead to positive results. For our series, Find Your Routine, we interviewed our most productive coders, reviewers and members of our education team, asking them what steps they take to find a rhythm that works for them.
This week, we talked with Beth Martilik, MA, RHIA, CDIP, CCS, Assistant Director of Education, about the steps she takes to find her routine.
Beth Martilik, MA, RHIA, CDIP, CCS, is the Assistant Director of Education at Health Information Associates
Q: Explain your role at HIA.
A: The Education Department at HIA is committed to providing quality educational resources to our coding staff to maintain the best-of-the-best reputation we enjoy with our clients. A major component of our ongoing education is the Sharepoint Coding Q&A site. Staff can submit difficult or confusing cases for assistance in coding. My primary responsibility is to research these cases and provide any education or recommendations back to the coder.
In addition to Sharepoint, I also assist in the development of Action Plans, one-hour modules that address specific topics that may present problems to the coders. It is critical that coders keep learning and expanding their knowledge of disease processes and surgical procedures. The Action Plans allow the coder to focus on any areas of weakness, either understanding a condition or procedure, or further training on coding dilemmas.
Q: Explain the process you use when answering any questions that are posted. What references do you use?
A: The process is simple. I read the question first to get a clear idea what the coder wants to know. Coders/reviewers are encouraged to be specific with their questions and not just ask if their codes are correct. This allows me to target the problem area only without recoding of a case.
Once I know what I need to look for, I review any documentation that the coder has attached. We require the coder/reviewer to attach any pertinent documentation that may help to answer the question. This adds a little more time to the process for the coder but allows for the most accurate and complete response.
I make use of all the usual coding resources, including Coding Clinic, CPT Assistant, and Coding Clinic for HCPCS. Anatomy references are a must in deciphering difficult procedure notes. My best friend is YouTube because I find it much easier to code a procedure if I can visualize it first.
Q: How many questions do you answer on a daily basis?
A: We average 15-20 questions per day.
Q: How does this help HIA’s coders maintain their productivity goals?
A: We encourage our coders to submit questions to Sharepoint only after they have attempted to find the answer. HIA has a bank of over thousands of questions and answers that can be accessed. However, in many cases research may take a great deal of time. If a coder has not come to a satisfactory resolution of their question in 10-15 minutes, we ask that they go ahead and submit the question to Sharepoint. This will allow the Education staff to further research the question and permit the coder to maintain productivity for the client. It is not unusual for it to take an hour or more on some difficult operative notes in order to recommend appropriate codes back to the coder.
Q: What advice would you offer coders to stay ahead of the rising productivity standards in our industry?
A: The more a coder knows, the easier it is to code a record. I would encourage coders to take advantage of any educational opportunities to learn more about different medical conditions and surgical procedures. YouTube is a great resource and it is free!
Latest News
Coding Tip: Cardiac Catheterization Coding in ICD-10-PCS
With the implementation of ICD-10-PCS the description of codes became much more detailed to describe exactly what is being performed. Cardiac catheterization is one of the descriptions that changed to further detail exactly what is being performed during the procedure.
Part 1: CPT Breast Education Series | Overview of Breast Reconstruction
This is Part 1 of a 6-part series focusing on CPT coding of reconstructive procedures following mastectomy. There are many different types of breast reconstruction procedures, each having potential stumbling-blocks for coders. Part 1 is an overview of the types of breast reconstruction techniques commonly used. Future topics in this series will go into more detail of each technique and the CPT coding implications.
ICD-10 Codes for Your Favorite Christmas Movies
With Christmas fast-approaching, we’re making a list of our favorite holiday movies and checking it twice. And in the spirit of good humor and cheer, we’ve added some ICD-10 codes to these holiday classics. Have a safe, happy, and healthy holiday everyone!
Coding Tip: Coding Lobar Pneumonia
“Lobar” pneumonia references a form of pneumonia that affects a specific lobe or lobes of the lung. This is a bacterial pneumonia and is most commonly community acquired. Antibiotics are almost always necessary to clear this type of pneumonia.
Part 5: Sepsis Series | Reasons for Denials and Prevention
Why are so many sepsis records denied? It’s hard to say why there seem to be so many sepsis denials of late, but most likely this is due to the multiple sets of criteria for the diagnosis of sepsis, change in definition of sepsis, as well as physician documentation.
Part 4: Sepsis Series | Are Clinical Indicators Present to Support the Diagnosis of Sepsis?
In Parts 1, 2 and 3 we learned about what sepsis is, sequencing of sepsis and what documentation is needed to report severe sepsis. In Part 4, we will look at clinical indicators needed to clinically support the diagnosis of sepsis and determine if a query is indicated.
Part 3: Sepsis Series | Severe Sepsis Documentation and Reporting
Severe sepsis occurs when sepsis progresses and signs of organ dysfunction/failure develop. One site stated that approximately 30% of patients with severe sepsis do not survive. Patients may develop one organ dysfunction/failure, multi-system organ failure and/or septic shock.
Part 2: Sepsis Series | Sequencing the Diagnosis of Sepsis
In Part 2 of our Sepsis Series, we are going to focus on sequencing of sepsis when the diagnosis is clearly documented. Later in the series we will look at what to do when the diagnosis is not clearly documented.
Part 1: Sepsis Series | What is Sepsis?
In this series, we will learn what sepsis is or causes of sepsis, how to sequence the diagnosis in ICD-10-CM, what are the clinical indicators for sepsis, is a query necessary before reporting the diagnosis of sepsis, and how to prevent denials on sepsis records.
Part 4: New ICD-10 Codes and IPPS Changes
In the previous three parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2020 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2020.
Part 3: New ICD-10 Codes and IPPS Changes
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2020. On August 2, 2019, CMS published the Final Rule for IPPS (CMS-1716) FY2020 IPPS Final Rule.
Part 2: New ICD-10 Codes and IPPS Changes
In Part 1 of this 4 part series we discussed some of the new ICD-10-CM diagnosis changes. In Part 2 we present the significant ICD-10-PCS procedure code changes. There are 72,184 total ICD-10-CM codes for FY2020.
Part 1: New ICD-10 Codes and IPPS Changes
This is Part 1 of a 4 part series on the FY2020 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. There are 72,184 total ICD-10-CM codes for FY2020.
Part 14: Spinal Fusion Coding — Spinal Fusion Series Summary
We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/spinal-fusion-coding/.
Part 13: Spinal Fusion Coding — Harvesting of Autograft for Spinal Fusion
In Part 12, we focused on intra-operative peripheral neuro monitoring used during spinal fusion surgery. In Part 13, we are going to focus on harvesting of autograft and is it coded. Remember in Part 6, we learned that autograft is bone from the patient.
Part 12: Spinal Fusion Coding — Intra-Operative Peripheral Neuro Monitoring
In Part 11, we focused on identifying the computer assisted navigation used during spinal fusion surgery. In Part 12, we are going to focus on intra-operative peripheral neuro monitoring.
Part 11: Spinal Fusion Coding — Computer Assisted Navigation
In Part 10, we focused on identifying whether or not hardware from a previous spinal fusion is coded. In Part 11, we are going to discuss computer assisted navigation.
Part 10: Spinal Fusion Coding — Removing Hardware from Previous Fusion
In Part 9, we focused on identifying if decompression was also performed and if so, on which body part. In Part 10, we are going to focus on identifying if hardware was removed from a previous fusion site.
Part 9: Spinal Fusion Coding — Was A Decompression Done During Spinal Fusion?
In Part 8, we focused on identifying if a discectomy was performed, and if so, if it was a partial or a total discectomy. In Part 9, we are going to focus on identifying if a decompression was performed, and if so, was it of the spinal cord, spinal nerves or both?
Part 8: Spinal Fusion Coding — Discectomy During Spinal Fusion
In Part 7, we focused on identifying any instrumentation that may be used during a spinal fusion. In Part 8, we are going to focus on identifying if a discectomy is performed and if this is an excision or a resection of the disc.
Part 7: Spinal Fusion Coding — Identify Any Instrumentation or Device Used
In Part 6, we focused on identifying the type of bone graft product used for the spinal fusion. In Part 7, we are going to focus on identifying any instrumentation or device used.
Part 6: Spinal Fusion Coding — Identify the Type of Bone Graft Used for Fusion
In Part 5, we focused on identifying the approach being used for the spinal fusion. In Part 6, we are going to focus on identifying the type of bone graft used for the spinal fusion.
Part 5: Spinal Fusion Coding — Identifying the Approach Being Used for Fusion
In Part 4, we focused on determining the spinal column being fused. In Part 5, we are going to focus on identifying what approach is being used to complete the spinal fusion (anterior, posterior or both).
Part 4: Spinal Fusion Coding — Identifying the Column Being Fused
In Part 3, we focused on determining the level of the fusion(s) and how to determine the number of vertebrae fused. In Part 4, we are going to focus on identifying which column is being fused (anterior, posterior or both).
Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
In Part 1, we learned the diagnoses associated with the need for spinal fusions, and in Part 2 the need to identify if the fusion is an initial or refusion of the vertebrae. In Part 3, we are going to focus on determining the level(s) of fusion, as well as the number of vertebrae fused.
Part 2: Spinal Fusion Coding — Initial Fusion or Refusion
In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.”
Part 1: Spinal Fusion Coding — Diagnoses Responsible
This is Part 1 of a 14 part series focusing on education for spinal fusions. Spinal fusion coding is a tough job for coders. There are so many diseases/disorders that result in the need for spinal fusion, and even more choices in reporting the ICD-10-PCS codes.
What’s the Best Defense? A Good Offense
The official definition from the Centers for Medicare & Medicaid Services (CMS) states that a Medicare overpayment is a payment that exceeds amounts properly payable under Medicare statutes and regulations. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government.
Query Tip: Writing a Query Question – Simple and Concise is the Key
The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking.