CodersGrade® Medical Coding Internship

Course Objectives

  • Hands-On Experience: Gain practical experience in real-world medical coding scenarios, enhancing your coding accuracy and speed.
  • Skill Development: Strengthen your knowledge of ICD-10-CM, CPT®, HCPCS Level II, and other coding systems.
  • Career Advancement: Improve your employability and competitiveness in the job market with valuable internship experience.
  • Mentorship and Guidance: Receive one-on-one mentorship from experienced medical coding professionals.
  • Networking Opportunities: Connect with industry experts and peers, expanding your professional network.
  • Resume Enhancement: Boost your resume with relevant, hands-on experience that employers value.
  • Industry Insights: Learn the latest coding guidelines, regulations, and best practices directly from the field.
  • Flexible Learning: Participate in a flexible, remote internship program that fits your schedule
  • Develop the expertise to read and interpret operative notes accurately, ensuring correct ICD-10-CM, CPT®, HCPCS Level II, and modifier coding for various general surgery procedures like hernia repairs, breast surgeries, and transplants.
  • Enhance career prospects with an additional certification, as data consistently shows that more credentials lead to higher salary potential.
  • Master the skill to read and abstract physician office and operative notes for precise ICD-10-CM, CPT®, and HCPCS Level II code assignments.
  • Gain a thorough understanding of Evaluation and Management (E/M) guidelines for various settings, including office, outpatient, consultations, and hospital services.
  • Learn Medicare billing rules and regulations, including scenarios like "incident to," teaching situations, shared visits, consultations, and global surgery billing.
  • Acquire specialized knowledge in coding various surgical procedures performed by general surgeons, such as gastric bypass, breast biopsy, skin grafts, and more.
  • Deepen your understanding of medical terminology, anatomy, and physiology to ensure accurate and compliant coding practices.

Table of Contents

Orientation

CodersGrade Medical Coding Internship

The CodersGrade Medical Coding Internship is designed to provide participants with a practical opportunity to apply their coding skills in a real-world setting. This immersive experience serves as a crucial component of your professional education, acting as a capstone to demonstrate your expertise and readiness for the medical coding industry.

By participating in this internship, you will refine your skills, gain hands-on experience, and bridge the gap between academic learning and professional practice, ensuring you are well-prepared to excel in your medical coding career.

ICD-10-CM Practice

Surgery Coding Introduction

How to Code from Operative Reports with Confidence and Precision

How to Code from Operative Reports

 

Diagnosis Code Reporting:

    • Use the post-operative diagnosis for coding unless additional or further-defined diagnoses are found within the body of the operative report.
    • If available, utilize findings from the pathology report for diagnosis.
    • Example: If the post-op diagnosis confirms a benign lesion, but the pathology report reveals malignancy, the malignant code should be used.
  • Start with Procedures Listed:
    • Always read the note entirely to verify procedures listed in the header.
    • Procedures in the header may not always be correct; cross-check with documentation in the body of the report.
    • Example: The header lists a laparoscopic appendectomy, but the body reveals the procedure was converted to an open appendectomy.
  • Look for Key Words:
    • Focus on keywords like locations, anatomical structures, surgical approach (e.g., laparoscopic, open), procedure method (e.g., incision, drainage, repair), and other critical details.
    • Example: "Laparoscopic" cholecystectomy vs. "open" cholecystectomy – these keywords change the procedure code.
  • Highlight Unfamiliar Words:
    • Research any unfamiliar terms to ensure accurate coding.
    • Example: If “arthrodesis” is unfamiliar, look it up to confirm it means the surgical immobilization of a joint.

 

  • Read the Entire Report:
    • Every procedure reported should be documented within the body of the report.
    • Pay attention if procedures were abandoned or complicated, which might require modifiers or a different procedure code.
    • Example: Planned laparoscopic procedure converted to an open procedure due to complications, requiring modifier 22 for increased work.

Tips for Handling Operative Report Nuances:

  • Modifications During Surgery:
    • If a procedure is more complicated or takes longer than expected, a modifier 22 may be necessary to indicate the additional work.
    • Example: A routine hysterectomy involves significant time due to dense adhesions, which must be documented to support modifier 22.
  • Unable to Complete Planned Procedure:
    • If a planned procedure is abandoned or not fully performed, note the reason for using a different code or modifier.
    • Example: A full colonoscopy was planned, but due to twisted anatomy, the procedure was incomplete, requiring a code for a partial colonoscopy.
  • Unexpected Findings:
    • Document additional procedures performed due to unexpected findings.
    • Example: During a laparoscopic cholecystectomy, a common bile duct blockage is discovered, requiring the procedure to be converted to an open surgery.

Documentation and CPT Codes:

  • Preoperative and Postoperative Diagnoses:
    • Always document relevant pre- and post-operative diagnoses, including underlying conditions affecting the surgery.
    • Example: Pre-op diagnosis is “mass – unknown pathology.” Post-op diagnosis reveals “malignant tumor” based on pathology findings.
  • Surgeon and Assistants:
    • Clearly differentiate between the primary surgeon, assistant surgeon, and co-surgeon roles.
    • Example: When two surgeons collaborate, ensure their roles are distinct to avoid confusion during coding.
  • Procedures Performed:
    • Procedures should be documented in CPT terminology but avoid using CPT codes in the operative report.
    • Example: Instead of writing “CPT 29881,” document “partial medial meniscectomy.”
  • Indications for Surgery:
    • Briefly explain the clinical necessity of the surgery, including past surgeries or the need for staged procedures.
    • Example: If it’s a planned stage of a wound reconstruction, note this to support modifier 58 (staged procedure).

Complexity and Additional Procedures:

  • Modifier 22 – Increased Complexity:
    • Clearly document any additional complexity or time involved in the surgery to justify the use of modifier 22.
    • Example: An extensive lysis of adhesions that requires additional time and effort should be documented to support modifier 22.
  • Details/Description of the Procedure:
    • Provide a detailed description, including patient positioning, anesthesia, special equipment used, and every action performed by the surgeon.
    • Example: Document “robot-assisted laparoscopic hysterectomy” to support billing for robotic assistance if relevant.

Steps for Accurate Surgical Coding:

  1. Review the Header:
    • Check pre- and post-op diagnoses, procedures listed, and other key information.
    • Example: Pre-op diagnosis – osteoarthritis of the knee, post-op diagnosis confirms the same.
  2. Review the CPT Code Book:
    • Verify potential CPT codes based on procedures documented.
    • Example: Arthroplasty of the knee has different codes depending on whether it’s a partial or total replacement.
  3. Review the Documentation:
    • Check the body of the operative report for key details supporting the codes.
    • Example: Verify that the knee replacement involved only the medial compartment to support a unicompartmental code.
  4. Make Preliminary Code Selection:
    • Based on the operative report, select the appropriate CPT code(s).
    • Example: A unicompartmental knee replacement is coded differently than a total knee replacement.
  5. Review Guidelines for Preliminary Codes:
    • Double-check any relevant CPT guidelines to ensure compliance.
    • Example: Check whether specific technology used (e.g., robotic surgery) requires additional coding.
  6. Review Policies and Eliminate Extras:
    • Review NCCI edits, local coverage determinations, and payer policies to ensure accurate code selection.
    • Example: Make sure bundled services or procedures that cannot be billed separately are excluded.
  7. Add Necessary Modifiers:
    • Apply modifiers to indicate laterality, complexity, or staged procedures.
    • Example: Use LT to specify left knee when coding a knee replacement.

Frequently Asked Questions

When does the course start and finish?
This course is completely self-paced, so you can begin at any time and set your own pace.
How do I access the course?
Once you sign up, you will receive an email invitation to join the course. You can access the course from any device with a live Internet connection. The course will work on a desktop, laptop, tablet, and smartphone.
What are the advantages of taking this course online?
Online courses provide unparalleled convenience and flexibility. You can take the course anytime and anywhere, on any device you own.
How do I ask questions?
You can email your instructor directly or utilize the course discussion board.

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