My Story of Certification

Oh dear, I can still remember finding out that I had to get certified, the immediate feeling of fear overwhelmed me! I had test anxiety and thought if a job depends on me getting certified it probably won’t happen. You see I did not have much confidence in my coding ability. (just at this time I have it now, LOL)

When I was getting ready to graduate my instructor asked me a question that would change my life. She asked me if I would come back and help her teach Medical Coding! Oh, my goodness at the time I did not realize the weight of this question, she was terminal and needed help in keeping the Medical Coding program in which she developed from the ground up functioning. I thought about it and agreed so off to the University we went to get me enrolled to get my Bachelors Degree! I remember having a lot of feelings about this adventure! I started back to school the fall after I graduated from the Jr. College. I loaded my schedule every semester and finished my 4-year degree in just 2 years!

I graduated in May of 2010 Applied and accepted my teaching job in June of 2010 then scheduled to take the CPC exam for August. Now, remember that for the past 2 years I had been completely focused on getting my bachelor’s degree so no coding for me.  I only had a short time working in a local medical office but it was front office mainly not a lot of coding. I hit the books hard and began studying– I had no clue what I was getting myself into!

I worked on my study guide from the front to the back and then from the back to the front I ate, slept, dreamt of this CPC exam for 2 months yes you heard that right just 2 months of preparation after 2 years of not coding, I was so nervous that I would not pass this test.

I will always remember the day I went for my test like it was yesterday– I had stress induced sinusitis I was sick…. I went into the testing room it was beginning to fill up. I carefully chose my desk got my books and pencils out, the lady sitting in front of me turned around and said I can tell this is your first time, I said uhh yes it is my first time, she quickly said (and she seemed proud about it) this is my 3rd time taking it. I began feeling very nervous I needed to pass this test this time!

The proctors entered the room and welcomed us, she asked how many it is the first time, I was the only one who raised their hand. Oh my goodness what is happening, I remember feeling sick at my stomach.

It was time to begin, I opened my test booklet and it was blank literally blank page I don’t know if it was the last moment of panic that took the words away but I was looking at white pages, I shut my eyes took a deep breath and when I opened my eyes the words were there!

I began the test and for what seemed like forever I finished the test and turned it in, I realized I was the first one finished and when I got to my car and looked at the clock realized I still had 2 hours left. I cried the entire way home I knew I blew my chance of passing

I was super anxious awaiting the results, my family had taken a vacation west to see family and it was there that my instructor, my mentor, my friend called to encourage me to check my scores on the AAPC website.  I logged on to the computer and on to the AAPC website only to find a CPC-A behind my name and man did I scream for joy 🙂

The great adventure began then– I now loved taking exams and had a great desire to sit for more certification exams.

I love the challenge in a certification exam– I would encourage any coding student to sit for the CPC exam it makes a way for many opportunities–

I have a great passion for teaching coding and help those who want to sit for the certification exam have a successful experience!

Happy Coding

Danielle

Modifiers– What is the big deal?

What happens when routine encounters or procedures are not so routine after all?  Things don’t always go as planned we have to have a way to say when something out of the ordinary happens during a routine encounter or procedure.  Remember that

Things don’t always go as planned we have to have a way to say when something out of the ordinary happens during a routine encounter or procedure.  Remember that

Remember that coders are storytellers, relaying the story of the encounter to insurance companies so that providers get optimum reimbursement for services rendered to the patient.  How do we as coders explain to the insurance company if a procedure took twice as long or perhaps did not take as long to complete as it typically does?

Modifiers are the answer to our question! typically 2 digits sometimes alphanumeric and sometimes numeric and sometimes only letters.

Modifiers are used to further explain the encounter or procedure, modifiers explain if a procedure went beyond the typical time, didn’t take as long as it normally does, or maybe the radiological exam was completed on both sides, the ear surgery to place eustachian tubes was only performed on one side when typically it is a bilateral procedure.

One of the most common reasons for rejecting a medical claim is the misuse of modifiers. You can find a list of modifiers in the front of your CPT book, HCPCS book. A description of modifiers is found in Appendix A of the CPT book.

Preparing to take the CPC

Are you preparing to sit for the CPC?

How do you feel about it? There are numerous feelings associated with this process that are completely normal… scared to death, nervous, anxious, excited, smart, prepared, not prepared, slow, crazy, wants to cry, wants to laugh, headaches, and more!!!

Really if you have never sat for a board exam these feelings are real and can be overwhelming if you don’t know how to control them!

My biggest advice is not to schedule the exam until you are prepared to take the exam! Do not rush into this as it is a big deal, and you need to prepare for every step! Follow the steps below and you will succeed!

  1. prepare by going to a local junior college, or an online program, or an approved AAPC instructor site
  2. get your books prepared– see former blog post explaining this process
  3. create a study plan
  4. know the guidelines for ICD-10-CM, CPT, Coding, Medicare
  5. purchase study guide from AAPC
  6. purchase practice exams from AAPC(there are others but I find that the AAPC are the best since this is the creator of the exam)
  7. once you have prepared and feel like you are ready schedule your exam
  8. continue to prepare

once your study guide arrives go through the entire study guide starting at page 1 and working your way through each page– taking it seriously do not skip around study each section in depth– anything you are unsure of make sure to make notes in your coding books!

Once you have finished going through your study guide– it is time to take a practice exam– this is where you really need to be serious and set aside time and a place that you will have silence– you need to get a kitchen timer or use your phone set the timer and begin your test– your goal is to get your time to under 2 minutes per question (don’t worry if you don’t have it the first time you take the test)

Take the practice exams until you get a 80% on the practice exam this will ensure that you are proficient and efficient in taking the CPC and you are now ready to sit for the real deal!

You need a 70% to pass the real test but with the practice exams if you can make an 80% you should be setting yourself up for a successful experience sitting for and passing the CPC exam*

Make sure to be completely honest with yourself when studying and taking the practice exams– if you are not then you will not be 100% ready to take the exam successfully! Remember that when taking practice exams getting an 80% on an exam that you had already taken will not count– you will take different practice exams until you reach 80%

You can reach practice sheets on this blog as well as the AAPC webiste

Good luck in preparing for your exam remember to always stay positive!

Happy Coding

 

 

*reaching an 80% is only to be on practice exams never attempted before(make sure to purchase multiple practice exams when preparing) It doesnt count if you had already taken the exam

Organizing your books

You may not think you have to get your books ready so you can take your CPC exam.

Organization is key when getting your books ready to test!

I like to color code everything

  • yellow
  • orange
  • green
  • blue
  • pink
  • purple

I get highlighters, pens, and post-it note tabs in these colors

I need to draw my attention to certain things in my code books so I use highlighters and pens to do the job!

Yellow is for any definition I need to know

Orange is for guidelines

Green and blue are for Cat and kitten codes(more about that later)

Pink is for your actual test you will use this for questions in which you have answered but need to come back to double check answer. You will use this on the exam booklet to highlight the code scenario key terms you are looking for

purple is for your actual test  you will use this for questions in which you could not answer and had to skip, you will have to come back and check these out! You will use this on the exam booklet to highlight the code scenario key terms you are looking for

You will want to begin by getting your current year version of each of the code books(ICD-10-CM, CPT, HCPCS)

There is a video below showing you my color coding technique

Do not over-highlight as this can distract you and the purpose is to draw your attention

Like what you have read here? See the full content available for purchase above

Happy Coding

Danielle

Evaluation and Management

Coding for an office visit, home visit, hospital inpatient services and more are all found in the evaluation and management section.

It is of the utmost importance that Medical Coders be aware of the guidelines that are associated with E/M and how to level out an E/M code.

It can be overwhelming to new and experienced coders alike I am going to try to help make E/M an easier concept for you today!

Grab your CPT book and follow along… a video will be posted below too

Starting with Office and outpatient services

There are 5 levels of codes for new and established patients

according to the CMS website a new patient is

New Patient:
An individual who did not receive any professional services from the
physician/non-physician practitioner (NPP) or another physician of the same specialty
who belongs to the same group practice within the previous 3 years

Established Patient:
An individual who received professional services from the
physician/NPP or another physician of the same specialty who belongs to the same

group practice within the previous 3 years

(cms.gov, evaluation and management guide, 2016).
When you begin coding and look at the chart the first question you must ask yourself is what type of patient are we dealing with? New or Established
For all new patients you will need to meet all 3 key components through documentation and for all established patients you will only need to meet 2 of the 3 key components through documentation
Remember documentation is your friend and like best friends that tell each other everything you need your documentation to tell you everything about the visit.
Leveling the code
you will see when you turn in your CPT book to the beginning of E/M section(see video below) that you have 5 levels of codes to choose from starting from a problem focused exam all the way to a comprehensive exam (the levels add in intensity)
There are 3 key components
  1. exam
  2. history
  3. medical decision making

you will need to know which set of guidelines your provider is using(I will link to the official guidelines below)

1995 or 1997 guidelines– according to the CMS a provider can choose which guidelines to follow, use the set of guidelines that are most beneficial to the provider

It will definitely help to have an E/M audit tool to help you get to the right level but this is a whole new post coming soon:) in this particular post I just want to give you a brief overview of the E/M section!

EXAM

HISTORY

This key component has a 8 sub-components

HPI(history of present illness)

  1. location
    • where the patients chief complaint is located
      • example: patient presents with nasal congestion and headaches, post nasal drip
        • the location is in the head(respiratory system/ sinuses)
  2. duration
    • how long has the symptoms been happening
      • example: the patient began suffering from congestion 5 days ago
  3. timing
    • when does the symptoms happen
      • example: the patient experiences a heavy feeling in the head at night and symptoms seem worse first thing in the morning
  4. quality
    • explains the signs and symptoms(dull, heavy, sharp, stabbing….)
      • example: The patient describes the pain as a dull pain almost like a toothache that wont go away, the throat is beginning to feel a burning sensation more than likely from the drainage patient is experiencing.
  5. severity
    • on a scale of 1-10 how bad are the symptoms(you will typically see this for a pain scale)
      • example: on a scale of 1-10 the patient says that her symptoms are a 9
  6. associated signs and symptoms
    • any additional signs and symptoms that are not necessarily part of the main chief complaint
      • example: patient expresses that the past 2 days she has felt nauseous patient denies vomiting or diarrhea
  7. Context
    • what happens when the symptoms are apparent
      • example:
  8. modifying factors
    • this is anything that makes the signs and symptoms worse or better
      • Patient expresses that the symptoms are relieved only during a hot steamy shower, working seems to make it worse as the patient works in a chemical plant(very noisy and bright lights)

ROS (review of systems)

Review of systems is basically an inventory of body systems this is where the provider asks a series of questions to the patient regarding his/her signs and symptoms and chief complaint. the following is a list of the systems included in the ROS

  • Constitutional
  • Eyes
  • ™Ears, nose, mouth, throat
  • ™Cardiovascular
  • ™Respiratory
  • ™Gastrointestinal
  • ™Genitourinary
  • ™Musculoskeletal
  • ™Integumentary (skin and/or breast)
  • ™Neurological
  • ™Psychiatric
  • ™Endocrine
  • ™Hematologic/lymphatic
  • ™Allergic/immunologic

PFSH(past family social history)

this section will include any relative family history, social history includes marital status, and alcohol, smoking, recreational drug usage…

MEDICAL DECISION MAKING

The work that goes into the patient visit, any labs ordered that needs to be reviewed, any medication changes, any risk to the patient,if the problems are worsening or improving

Conclusion

Evaluation and management is a complex section of procedural coding and this is the focus of many medical audits! Medical Coders want to be well versed in E/M coding to be successful.

 Do you feel you need a review session on E/M? You are in luck  Americode Professional Coding has just that– a Complex review session on E/M– each component of E/M is broken down into a lesson– Interested yet? find the entire course list above
Happy Coding

Coders are story tellers

Are you a story teller, do you love putting stories together, do you love reading stories, do you love stories?

You may be a medical coder

Providers are story tellers– what happens during the encounter are written in the EHR/EMR so that medical coders can then relay the story to insurance companies.

As medical coders we have to be able to be great story readers and story tellers

No one is in the encounter except for the provider and the patient. Providers need to be able to convey everything that happened during the encounter, so that when the coder reads the documentation it is as if the coder was also in the exam room during the encounter.

Specificity is important, laterally is important, not abbreviating and taking shortcuts is important

Coders want to give their providers the benefit of doubt however if it isn’t documented it didn’t happen, I don’t care how close you are to your provider and you know his/her routines and think it doesn’t matter if it is documented, it does matter. It is always better to have too much documentation than not enough.

In many circumstances providers actually code their own encounters and the certified coder is responsible for spot checking their code selection, remember it is okay to make changes if the code selected isn’t correct. If you the coder know it isn’t correct but submit it anyway you will also be liable if there is fraud/abuse with the claim forms.

Remember that providers tell us (coders) the story of the encounter then we translate their story into medical codes which then tells the insurance companies the story of the encounter.

You the coder are the deciding factor if there will be a happily ever after to the story!

Happy coding