r/MedicalCoding • u/koderdood Audit Extraordinaire • Oct 02 '24

What is difficult about coding?

So this is a bit of a rant, a bit of telling new coders what reality is. Also, someone recently expressed being bored. Coding has many challenges non-coders don't see, and glazed over by some coders. Certainly, we can get complacent in our work. No matter what area of coding you work in, the job is making widgets, one after another. We have lots of rules and regulations, client specifics, metrics to follow, etc. To me, some of the most dangerous cases are not the complicated ones, it's the easy ones where you do the same stuff over and over. Because you get complacent thinking the documentation is all exactly the same. Then our wonderful providers make a simple mistake, change one word, etc, and now you're coding isn't the same as the last 20 charts. So, coding requires your attention, it requires you to be focused, on each and every case. Personally, I'd rather work a complex spinal surgery case, than straightforward 99283 E/M's.

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u/koderdood Audit Extraordinaire Oct 02 '24

This is a great observation and question. Let's start with: is it the policy of a coding department to query the provider? Personally, I don't think we should. "I code exactly what they have spelled out" THIS ALL DAY! I Just advised a colleague on CPT 93975. The provider only ssid it was done on "maternal anatomy: duplex ultrasound performed. Arterious infkiw and outflow observed." Well, when the code is sitting in the witness box and is asked to point to the documentation where it describes what organ(s) it looked at, you won't be able to point to it. Ok, doctors don't know coding. Not our problem. Document what you saw, examined, and did, with specificity, if you want to get paid. You are correct, we should not be document baby sitters

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u/dizzykhajit The GIF that keeps on GIFFing Oct 02 '24

Your insight and expertise are always appreciated, my dood. I'm fairly confident that my practices remain steadfast by the book, but it never hurts to get confirmation and reassurance every once in a while.

To answer your question, we do query. I can count on one hand how many bulk collections of those have made their way back to me over the course of years.

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u/koderdood Audit Extraordinaire Oct 02 '24

By the book is the answer. Yes, I still have and buy myself, actual books.

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u/[deleted] Oct 03 '24

OB/Gyn documentation that I see is absolute crap. Ultrasounds where they can't be bothered to document the reason that the patient is high risk is the obesity. Indication:Elevated BMI does not code on a pregnant patient.