Alicia: We’re going to do a Practicode case.
This is one that stumps a lot of people.
Laureen: Alicia, before you get started, for those that don’t know, can you briefly explain
what Practicode is?
Alicia: Practicode is a company that offers a service with real redacted scenarios or
cases or encounters.
So, they’re multispecialty and there’s about approximately a 100 to 150, sometimes
more, individual encounters in these specialties.
Anything from cardiology to gastroenterology to family practice and fee-for-service and
ICD-9, ICD-10; so we offer this as an additional course that students can take where they’re
wanting real life experience.
This isn’t necessarily a good thing to go through if you haven’t tested for the CPC,
this is meant to help you really work on specialties and abstracting of real cases, not scenarios
that were created to drive home a guideline.
So, if you think you want to do cardiology or something, then this is going to help you.
Laureen: So, you get certified and now you’re working hard to getting that first job.
This is a perfect thing to do in that gap to get your speed up, and here’s an example
of one of the cases.
By the way, Alicia conducts a support call every Thursday night when we’re not doing
this call, and she has all of the MCP, that’s our medical coding practicum students on the
first hour, then the coding students the second hour, and our Blitz customers the last half
hour.
She goes over a lot of these cases and really the students get a lot out of it.
Alicia: Practicode is a company that offers a service with real redacted scenarios or
cases or encounters.
So, they’re multispecialty and there’s about approximately a 100 to 150, sometimes
more, individual encounters in these specialties.
Anything from cardiology to gastroenterology to family practice and fee-for-service and
ICD-9, ICD-10; so we offer this as an additional course that students can take where they’re
wanting real life experience.
This isn’t necessarily a good thing to go through if you haven’t tested for the CPC,
this is meant to help you really work on specialties and abstracting of real cases, not scenarios
that were created to drive home a guideline.
So, if you think you want to do cardiology or something, then this is going to help you.
Laureen: So, you get certified and now you’re working hard to getting that first job.
This is a perfect thing to do in that gap to get your speed up, and here’s an example
of one of the cases.
By the way, Alicia conducts a support call every Thursday night when we’re not doing
this call, and she has all of the MCP, that’s our medical coding practicum students on the
first hour, then the coding students the second hour, and our Blitz customers the last half
hour.
She goes over a lot of these cases and really the students get a lot out of it.
The first thing we’re going to look at is: what is his chief complaint, his chief concern?
Now we know he’s here for a hospital follow up.
The next thing I like to do is scroll down to the bottom of the document and this is
kind of the auditing and risk adjustment part of me.
I always check to make sure there is a good signature.
We’ve got electronically signed by our doctor with a credential and a date.
A real electronic signature would also have a timestamp on there.
Then I want to look and see, what does he say is the diagnosis?
That will just be right above there.
It’s usually Diagnosis or Assessment.
In this assessment, it says lower extremity swelling secondary to post-CABG.
Right there, we know he came in for a follow up, but this is the diagnosis that he’s
given and this is what he plans to do to treat it.
Now that we know what’s going on, we’re going to go back up to the top and let’s
look at the HPI or the History of the Present Illness and find out if that’s the only
thing going on.
Go to the Problem List, this one is set up a little bit different.
They listed the Problem List first.
Now, keep in mind we know that they’re there for a hospital follow up, so that could be
several diagnoses.
We know what was in the Assessment.
Keep in mind also, lots of things to keep in mind, what type of coding are you doing?
If you’re doing risk adjustment, it’s a whole different set of things you’re looking
at versus coding this for the office.
A problem list is often copied and pasted.
You don’t really want to code off a problem list because it can have things that are outdated,
but it shows a continuum of care of what’s going on with this patient, so it’s important
that we need to look at it.
We have more information.
We know what type of a CABG this patient had.
We know the reason was an abnormal EKG.
Then, the other things, we know he’s five years status post prostate cancer.
He has hyperlipidemia and he has vertigo, secondary to labyrinthine disorder.
Now, we also want to know, what did he come in for?
This is being coded for just a regular doctor’s office.
This isn’t risk adjustment or anything else.
We know he came for a hospital follow up, why was he in the hospital, and it tells us
right there because he had a CABG and then there was some problems and he an abnormal
EKG.
Where this trips you up, is that we’re not concerned about the other problem list.
We’re concerned about why he was seen for this encounter.
Now, there are things that can be applicable to that, but what is the focus in the diagnoses
that we’re given?
We look at the allergies.
Man, not really a big deal.
Medications are very, very important.
It lets you know what’s going on, and sometimes they’ll even be dates off to the side.
If you don’t know what a medication is, you need to go look it up even if it’s in
a Medication List and it’s not applicable to maybe your diagnosis.
But if you see this diphenhydramine, what in the world is diphenhydramine?
Go to, like, www.drugs.com.
Google it, it’s Benadryl.
If you don’t know that, you need to know.
The other medications that will jump out, we know
that they’re on potassium, that’s the KCl.
They’re on potassium because they’re on furosemide, which is a water pill.
Things like that.
So it lets you know what’s going on.
Now we’re going to look at the History and they’re going to tell us what he actually
did for the patient.
The patient is here for a follow up.
The EKG was off, he had a bypass.
If we look at the date, this is all like within the same day or something.
Then, he had no chest wound complications.
He presented to the office a week ago.
Everything in there, as I’m scanning, really says that he has a problem.
His legs remain swollen, worse after sitting for 30 minutes… and it’s even getting
swollen while he’s sitting there.
No fevers, no other reason for the cause.
Now we’re going to look at the Physical Examination.
Right now I’m going to focus on diagnosis.
I always like doing diagnosis first because I like the diagnosis part of it.
We’ll just do that first.
We’ll worry about the E/M later.
So now this is where you’re going to really pull the E/M stuff.
The previous stuff is what the patient is telling, the HPI.
He’s saying, “These are my problems” and the doctor will ask questions, like, what
makes it better, what makes it worse?
But these are the questions the physician is asking and the patient is telling.
Then, when you get to the Physical Exam, this is when the doctor is actually putting their
hands on the patient.
This is what the doctor observes, not what he’s being told, but what he is coming to
a conclusion with.
So it’s two separate parts.
This is very, very important so you want to scan this and look to see if you have anything
that jumps out.
This is where you’ll see a lot of things that you say “negative” or “no” but
we know that he has a problem with his extremities.
His cardiovascular, that all looks good, except for – isn’t that funny that it says, and
this is where they get into copy and pasting and you can tell he messed up on this because
we know his legs were swelling while he was sitting there.
It says, “No murmur or clicks…
Femoral, tibial, dorsalis pedis pulses intact.”
You got swelling; they want to know is it cutting circulation?
“No leg swelling.”
That’s a copy and paste because right above that, it was swelling while he was sitting
there talking to doctor.
Anyway, you got to be very careful about what you’re reading.
The skin, it’s also where we’re going to see some… this contradicts it.
It says he has an incision.
“Both legs are significantly swollen, 3+.
No weeping noted.”
Now we’re talking about the integrity of the skin and stuff like that.
The Assessment: Lower extremity swelling secondary to post-CABG; and the Plan.
Now, let’s go look at the answers that we’re given.
These are the answers that Practicode gave us and then these are the answers and I just
drew this random first from a student; but these are very common that get coded.
One, they say it’s edema, but nowhere in the document did the physician state that
the patient had edema.
He constantly stated that he had swelling, swelling of the limbs.
That is actually, you can see two different diagnoses.
Then, he’s status post-CABG.
There’s a V code for that, that’s very pertinent to his care.
This is where you get into some funny things where it’s not always black and white.
It’s not edema, it is leg swelling.
It may change and become edema later, but he didn’t say edema and we can only code
what he states.
He has hyperlipidemia, but that wasn’t in the assessment.
Is it pertinent to his care for what’s going on?
Probably, but it’s not in his assessment.
That’s why they didn’t code it.
And the history of the prostate malignancy – is that pertinent to his bypass and what
the follow-up is all about, what’s going on?
No, not really.
If you could make a case that it’s part of the plan of care, but he didn’t address
that, that was a problem list.
We can’t really code off a problem list.
We already saw in this document how copy and paste will get you in trouble.
He said right there that there was no leg swelling and then he turned around and said
that there was leg swelling, so you have to be very careful.
If you’re ever in doubt about this, what you do is you go query the physician.
You ask him and say, “You said this was limb swelling, is this edema?”
If he says, “No.
It’s not edema.”
“OK, thank you very much for clarifying that.”
“Is his hyperlipidemia in any way pertinent to this?”
“No, it isn’t.”
“Is the fact that he is status post prostate – could that have anything to do with the
swelling?”
If he says, “Yes” then it’s pertinent.
Then, you’re coding that.
Then, you have your leveling, your E/M, that’s really in some part the easiest part.
They did several tests, he did exams.
You can click off all of the little parts of doing the exam for an outpatient and that
it’s an established patient and it got a 99214, but for the most part, it was going
to be a 99214.
But that right there is a little overview, that’s how we do it.
If we have questions about certain things, like, what’s the medication for hyperlipidemia?
We go look it up while we’re doing this, and we spend an hour doing 3 or 4 cases, sometimes
we may only get through two because we break it down, understand the disease process.
We do the E/M leveling together and we kind of joke about, so-and- so said it was a 214
and we picked the 213.
It allows several people with several backgrounds and levels of experience to work together
as a team and see how other people think.
Unlike these Q&A webinars, it’s interactive, and we actually talk to each other and you
can get a lot of insight from the students and their backgrounds and their experiences,
so that’s a lot of fun.
Laureen: How to tease it out.
Get that information out.
Alicia: Exactly.