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if you've heard about medical coding and
you're not quite sure what it is
stick around for this video because
today i'm going to discuss the
introduction to medical coding
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hey i'm victoria i'm a medical coder
auditor educator i've been in this
industry for over a decade and i've
published lots of articles and had
national speaking engagements on medical
coding
and today i want to talk to you about
the introduction to medical coding so
what is it
what kind of stuff does medical coders
do and what are the jobs of medical
coders
a medical coder is someone who
translates medical records and medical
charts into codes
mostly for diagnoses and services that
were provided
in medical coding there is cpt which is
current procedural terminology so those
are codes for a lot of procedures and
services
provided to patients then there is icd
the international classification of
diseases
and we use the cm which is the clinical
modification and then in the inpatient
and facility they use pcs the procedural
clothing system
hitpix is the healthcare common
procedural coding system and it contains
a lot of codes for things like drugs or
durable medical equipment
there's a lot of tools that you can use
online and through electronic medical
records that will help you select the
right code
but most coders prefer to use their
tried and true coding books
so here is your hit picks
i have an icd-10-cm i don't do inpatient
coding so i don't have a pcs book
and then the cpt book for your
procedural coding
medical coders use their electronic
medical records to review charts and
then assign the right codes that are in
their code books
even though there are electronic lookup
tools in order to sit for any medical
coding certification exams which are
needed to become a medical coder and
work as a medical coder
you need to have the paper books you
have to have the paper books to
test for there are two main entities
that employers trust for certification
of their medical coders and that's aapc
and ahima
those are our big brands i say that
they're the coke and pepsi of the
medical coding world
those are the ones we can we know and we
trust aapc
does mostly coding for provider-based
services so things that are done by
physicians and physician extenders
and then ahima is more known for
inpatient coding so coding for the
hospital coding for the room and board
and all the services that you receive in
the hospital as an inpatient
now there's lots of other certifications
out there a lot of technical schools
will offer
a discounted or even free certification
for the
cbcs through the nha and nothing against
that credential
but it's really not what's in demand by
employers there's a lot of different
places that medical coders could work
they could work just in a billing office
or they could work in a physician office
or a hospital
a surgical center nursing care the
emergency department
insurance offices they could work for
the government or for an ambulance
service
they could work for dme suppliers or
they could even work for dental services
although those type
tends to use a little bit of a different
type of coding the cdt which is the
current
dental terminology now if you want to
know about the typical day of a medical
coder i do have a video for that i'll
link it up and the card
above and i'll also link it in the
description below and i also have a
video you might want to check out
as far as skills that are beneficial to
the medical coder
and a video on if medical coding is
right for you
medical coding does require a lot of
reading of reports and reading of
medical records
and then using your tools to translate
them into
code it also requires a lot of
understanding of complex
guidelines not just coding guidelines
but sometimes insurance
federal state and government guidelines
in order to be a successful medical
coder you have to know how to not only
navigate those systems but your coding
books
there are lots of very complex coding
guidelines insurance guidelines and even
government guidelines
on the federal and both state level
there seems to be almost a
misunderstanding that these medical
coding books are basically like
dictionaries or
phone books that you just look up a
diagnosis or a procedure and you just
slap on a code and there's really so
much more than that
let's look at even a simple example so
here's a fairly simple case example
this patient has a perinekia of the left
index finger
so this is why you need to know medical
terminology because you need to know
what a perinecia
is in order to assign the correct code
for it perineke is when you get that
little
uh infected cyst on the like a hangnail
and stuff on your finger
after the area was anesthetized i then
prepped this area with bentatine
solution then was prepped in a sterile
fashion utilizing iris scissors i then
opened up the area of pus and tried to
express any pus
that was in that area there was no
evidence of felon septic arthritis or
obvious retained foreign body
i then cleaned out the area as best as i
could and there was a dressing that was
placed the patient tolerated the
procedure well
patient was giving instructions to keep
the area clean and to continue
a neosporin and band-aid for a couple of
days and return immediately if the
condition worsens
as we discussed so this um
this where he says he opened up the area
and expressed all the pus that's what we
call an incision and drainage
so an ind so when we would be looking up
the cpt code the procedural code
for this we would likely look under if
you're just learning coding you look
under the alphabetic index in the back
i would just go to the integumentary
system but for the sake of this
demonstration i'm going to show you what
you would do
when you're just learning is look for
the word drainage here in the index
and under drainage we have
abscess and then here we have
perinekia and that's 1 0 0 6 0
1 6 so that's where we go
in our code listing here in the front
so our integumentary one zero zero
one zero zero one zero
zero
one zero zero six zero is incision and
drainage of abscess
carbonyl supportive hydrogen ions
cutaneous or subcutaneous
abscess cyst for uncle or perennicia
simple or single
and then the one with six one is
complicated or multiple and this
wasn't really complicated he said there
wasn't any kind of
arthritis felon it didn't look like
there's complex
closure or anything like that involved
so we would go with this simple code
of one zero zero six zero
i apologize i have terrible handwriting
these are zeros
next we need to figure out our diagnosis
code so the diagnosis code for
perinekia
so we start with our alphabetic index
under p
and go to perinekia
p-a-r oh
parkinson's pear
right there uh see also cellulitis digit
okay so now we're not at the right code
here it's telling us to go somewhere
else it says c
cellulitis digit okay so we go and see
cellulitis digit over to our c's
cellulitis of
the digit finger c cellulitis finger
so the latest finger l03.01 and then it
wants us to put
on um an additional
digit l03
0.01 and then we always have to double
check
our diagnosis codes from the alphabetic
index in our tabular list so we go to
lo3
zero one cellulitis of the finger and
once at a right
left or unspecified this one here it
says
left the sixth digit that we need
is the two for the left finger so that
would be our total code so this is
what we would bill out the one zero zero
six
zero for the incision and drainage of
the perinekia
and then for the perinekia itself l zero
three
point zero one two so while that one
wasn't too hard
let's look at something a little bit
more complex
so here we have a case and i'm not going
to code this out but i just want to show
you for complexity purposes
that this is a case that is a
thromboendartectomy
of right common external and internal
carotid artery using internal shunt and
dacron patch angioplasty closure
coronary artery bypass grafting times
three utilizing left internal mammary
artery to the left anterior descending
and reverse
autogenic saphenous vein graft to the
obtuse marginal
posterior descending branch of the right
coronary artery
so you can see again medical terminology
understanding what you're looking at is
extremely important
and this is a very complicated case and
when you're working in coding you can't
just decide you're going to eat this
case
and not do it because it has to get done
and there is no going
oh this is too hard i'm just going to
skip it if you're a medical coder
there's no skipping of cases
it's your job to code it regardless of
how complicated it might be
or how many times you might have to go
back to that provider to ask for
clarification on what was done
so i hope that was a helpful
introduction to medical coding if you
think so make sure you give this video a
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because i'm posting videos twice a week
i will see you in the next video and
until then just keep on
coding on
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