Laureen: OK, Alicia, abstracting a coding case.
Alicia: Well, in our Thursday night lectures, webinars, we get together and often take a
case. And so, this is one that we did but I decided to do this because we had a question
coming.
Q: I need more practice pulling the important information out of the case and where to get
started.
A: This is actually a case on Practicode, and this is the way more less that it's set
up, you're going to have, ought to decide in Practicode where you're going to be able
to put in your codes. But what I did was since it's several pages long and that's - you're
not going to get cases on the exam that are several pages which you may get a page and
a half or a full page, and that should not intimidate you because some of that stuff
I like to call fodder and it's not really fodder but this information that you don't
necessarily need to pull out the proper codes.
So when I'm looking at this case, the things that are going to jump out at me when I'm
scanning it first to abstract the information, I put in purple. So, why did the person come
in for the visit, that's their chief complaint or the CC - they're dong med refill and bilateral
back pain. And in the HPI (history of the present illness), I noticed right off they
have GERD and then he goes in-depth about what's happening with the GERD. And then the
next thing - you've got three paragraphs or its cut there on one diagnosis. Then we have
back pain, so that jumps out at me; the person has back pain so we're going to find out more
information about that.
As we scroll down we're going to see, I think... that's all that he talks about in the HPI.
So right now I know they're going to refill meds, so we may have diagnoses for that but
he's having problems with GERD and he's having problems with his back pain. So, as we scroll
down we're going to start seeing what type of medications the patient is on which is
going to be a red flag as to other diagnoses that they could have. And I see a few that
jump out at me real quick. Carafate is used for GERD and ulcers and stuff. The levothyroxine
is a... the thyroid, no it's not thyroid that's Synthroid; anyway I know what that's used
for. And Prilosec also, that's taking care of that GERD, so he's going to get to refill
them. But those right there with no more extra information those jump out at me right away.
So I scroll down and something else that jumps, I always check is the past medical history, now they've done
a pretty in-depth social history, but the past medical history, these are things you're
going to look for, make sure that they haven't had an amputation like below the knee amputations
or that they've had cancer in the past. And this person actually has had cancer, or it
says "cancer - yes," so at that tells me, heads up, you might get to code something
that may not be talked about in another place on the chart, don't want to lose that. Also,
this person had surgical history of a hernia repair. Surgical history is also going to
give you a past medical history sometimes, again if they had an amputation or for some
reason you may need a V code.
I'm scrolling down a little bit more, let see... Now we have orders, it says: The following
orders were looked at: Prilosec, Carafate, and a levothyroxine, which again were the
ones that jumped out at me that are probably ones that they're going to be refilled due
to what they're being seen for whether they're saying their chief complaint is.
I'm going to scroll through to this pretty quickly because body systems when you get
to doing your E/M and your leveling, this is going to be important. Right now while
I'm trying to abstract out first the diagnoses - which I like the diagnoses first because
I just like diagnosis coding better than CPT, so that's where I focused on first. And nothing
jumps out at me. You got to be careful because sometimes they get in to copy and pasting
in these EMR's and you do want to watch for that when you're doing your E/M leveling.
OK scroll down a little bit more and let's see, he doesn't have a hernia that's palpable,
so I didn't highlight that. There's nothing here again that jumps out at me, so I didn't
highlight it. When you're going through this, you might circle it or highlight it yourself.
So, the assessment and the plan is going to be very important because this tells me exactly
what the doctor is treating, what he's doing. So, again, those medications and it's levothyroxine,
the Carafate, and the Prilosec. And then look, he says, he starts his diagnoses. We have
unspecified hypothyroidism - well, that's why they're taking the levothyroxine. We have
reflux esophagitis, which is GERD, and that's Carafate and the Prilosec. And then we have
a hernia, it says "other hernia of the abdominal cavity without mention of obstruction or gangrene"
- very important that it says without mention of obstruction, is that changes the code,
but we know it's the abdominal cavity.
And then after you get a little more familiar with your diagnosis coding and coding of hernias
and stuff, the word "diaphragmatic" is specific, that's the word you need to be able to find
the proper code. "Abdominal" is not going to get you anywhere, "abdominal hernia" well
that could be anywhere but "diaphragmatic" gives you a specific location, so that's that
word jumps out at me. And then hernia, and that is malignant neoplasm
of prostate, and I thought "Oh! OK." But there was nothing that I saw that jumped out at
me except for the history code of cancer, and it says prostate cancer, but then I would
go back and I start looking and saying, "Well, does he actively have prostate cancer at this
time?" I didn't see anything where he's had surgery; I didn't see any treatment or medications
they were treating for prostate cancer, the treatment of cancer. That gives me a heads
up especially when I saw that it was in the history section that he had prostate cancer
in the past.
So, we scroll down and let's see what we came up with. The E/M code - again, 99214 - the
things you want to know about that. He was very good about the HPI, very specific. Now,
if you have your E/M leveling sheet where you can go and click all that stuff off. We
don't have that here, but when you're doing that, the things that pop in your head are:
How specific was the HPI, how many body systems were affected, and did he review the social
history, the family history - all of that stuff - personal history. He brought all of
that in there.
Then, I was thinking at the back of my head, "How sick is this puppy?" and you have to
meet two of these three key components for an outpatient visit, for an established patient.
This 99214, which is a pretty high level, you've got a detailed history, a detailed
examination, a medical decision making of moderate complexity. You have to meet or exceed
two of those. Then, it goes into about counseling and stuff like that. He was going to have
the patient see his doctor that did the hernia operation in the past to check for this hernia.
Your diagnosis code 553.3 is going to be that diaphragmatic hernia, and again 553 is a hernia
but it's a diaphragmatic, so that's a 3. The 244.9 is going to be your thyroid. The 530.81
is GERD. The V-code, V10.46 is going to be a past history of prostate cancer. Then, I've
got those listed down lower on the page with their codes and their definitions. I just
haven't had those codes almost memorized because you see them a lot.
Again, you don't memorize codes but codes that you will see repeatedly often are things
like the hypothyroidism and the GERD - you'll see those recurring a lot. So, they're probably
will be ones that you tend to learn quickly. Laureen: And Tiffany and Cathy shared in the
chat that the drug levothyroxine is a generic form of Synthroid.
Alicia: OK. See, I knew Synthroid, I was thinking, "Wait that's Synthroid." Thank you ladies,
I appreciate that.
Laureen: Let us see. Someone shared reflux esophagitis is 530.11. Where could I go to
find common drug treatment for disease? I noticed Alicia mentions that often.
Alicia: I go to drugs.com and that's the one I started using but you have to keep in mind
that that is just going to get you in the right direction but you can go to WebMD has
one and some others. I just like the format of drugs.com.