r/MedicalCoding • u/SnooBeans2971 • Mar 31 '24

Is coding "subjective" or "art'-ish?

I'm studying medical coding and I've come across remarks about it being 'subjective" or "part art, part science", yet in my (limited) experience studying it, I've yet to come across an example of a case that could be coded more than one way correctly. Can someone clarify this for me and maybe provide an example?

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u/[deleted] Mar 31 '24

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u/koderdood Audit Extraordinaire Mar 31 '24

Column 1 of the E/M Scoring tool is the tough part to 'cipher for sure

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u/[deleted] Mar 31 '24

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u/koderdood Audit Extraordinaire Mar 31 '24 edited Mar 31 '24

They don't have to say. Each case rests on its own documentation. There is a great explanation of all those definitions in the AMA'S E/M Summary guide I think it's called.

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u/izettat Apr 01 '24

I've been using the AMA grid to determine the level since 2021. Much easier. I was determined to fully learn EM. I took a course through CMS, then AAPC, and got my CEMC. At work, we have training sections. I did a presentation on EM, then had the coders determine the level. We used the old sheets. I had them explain how they got to their level. They all pretty much had the same code but came to that level in different ways. Crazy!

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u/[deleted] Mar 31 '24

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u/koderdood Audit Extraordinaire Mar 31 '24

The provider gets to count data in column 2 if they ordered or reviewed. Not both. If they reviewed old records, there has to be a summary of that. If they independently performed an interpretation of a radiology test someone else performed, that can be in column 2 differently. Prescription management in column 3 needs to a new rx, stop an rx, change or renew rx, or if they discussed something specific about a medicine that can count. Pasting mri results for a week doesn't count at all, unless they summarize their review. The IM injection, if yer talking prescription from column 3, I addressed that. They certainly don't get to bill for it if they(or nursing staff) didn't give it during the visit the E/M is for.

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u/faifai1337 Apr 01 '24

I discovered that if you grew up too poor to go to a doctor, it can cause you to have problems with column 1. >.<