Cultivate Your Inner Data Detective

10 coding tips to help you solve the case of a patient encounter

1. Propose Relevant Questions-The first thing to ask yourself is, “What was done for the patient?” (laboratory visit, a surgery, a diagnostic, or a therapeutic)
2. Analyze Data from Different Source Documents-In the medical record there may be lab reports, radiology reports, medication lists, encounter notes, and visit summary reports, all of which can lead you to the correct code(s).
3. Research Unfamiliar Medical Procedures, Diagnosis, and Terms-The worst thing a coder can do is GUESS. If there is a diagnosis or procedure code that you have not come across before, LOOK IT UP.
4. Develop the Critical Thinker from Within-Critical thinking is at the core of being a professional coder, as you must make important coding decisions based on the information in the medical documentation.
5. Rely on Proven Resources-A good detective understands the power of reliable information.
6. Pay Attention to Detail and Accuracy-Taking the time to carefully review the documentation in the medical record is beneficial in diagnosis and procedure coding. The quality of your resources will directly affect the outcome of your coding.
7. Maintain Strong Communication Skills-There will be many times when you must query the physician to accurately code a case. Effective written and verbal communication skills will be helpful in querying a physician.
8. Use Robust Coding Software-ALL facilities have their own software packages.
9. Keep Up-to-date on Insurance Carrier Guidelines-Insurance carriers update guidelines often, and it is important for you to know the myriads of changes that can affect coverage.
10. Administer the Coding Process-Using the data, now that you have uncovered the who, what, when, where, and why along all coding guidelines and conventions, select your codes with confidence!