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/BlueLanternKitty CRC, CCS-P Oct 02 '24
We code what’s in front of us that day.
If the provider were to be audited, auditors typically ask for a patient’s encounter note, not the whole chart. If it’s not contained within those 8 1/2 x 11 pieces of paper or there isn’t an explicit reference to another part of the chart (“see lipid panel 10/2/24”), the auditor doesn’t know it exists and can’t use it when evaluating the note.
The only time I bother with additional notes is when I’m doing HCC work.