Medical Coding Can Be Made Efficient!
Medical schools and Residency programs do not provide education regarding proper coding and billing. For me, private practice was a rude awakening. There was so much to learn about the business side of medicine. ICD codes, CPT codes, Modifiers, E/M documentation requirements, Medicare rules vs. Private payer rules, Office staff payroll, Business Tax requirements, Patients filing for Bankruptcy, Referral patterns, and the list goes on and on. Suffice it to say, I survived. In the process, I developed efficiencies such as developing a Microsoft Access database program to track all my patients, date of service, place of service, diagnostic and procedural codes, etc. This came in very handy as I could easily generate reports of how many cases of each type I performed over certain timeframes. I also developed a timesheet and payroll calculator to handle payroll and tax requirements.
One of the largest hurdles was in 2015 when Medicare finally forced implementation of the ICD10 code set and retired the ICD9 code set. Overnight, the diagnostic code set went from 16,000 to 64,000 codes. For a few months prior to this, I had begun to develop an ICD9 to ICD10 crosswalk for the most common General Surgery codes I used. I printed this out and on October 1, 2015, I gave a copy of this book to my partners. The expected drop in efficiency never materialized for our practice. Since the book was organized by organ systems, my partners intuitively used it without any training.
As a proof of concept, I then began to add CPT codes and modifiers, I read up on Clinical Documentation Improvement, using APP’s, and viola… Coding Solutions: General Surgery book was born. In 2016 I became a CGSC (Certified General Surgery Coder) out of necessity since I was always being asked, “What does a General Surgeon know about coding?” Through this process, I learned a lot about obtaining a Copyright, Licensing the CPT from the AMA, and how to format and publish a book.
The 2021 Edition of Coding Solutions: General Surgery has a wealth of information on proper and efficient coding. It is very concise but encompasses about 95% of the situations a General Surgeon will encounter. I hope you find it helpful in your practice and I would love to hear your feedback, whether it be positive or negative.
Below is the full Table of Contents of the book.
1. E/M CODING AND BILLING
2. ABDOMEN
3. ABNORMAL IMAGING + TESTS
4. ABSCESS / CELLULITIS
5. ANAL + PILONIDAL DISEASE
6. APPENDIX
7. ASCITES
8. BREAST
9. BUNDLES
10. COMPLICATIONS: INTRA-OP, POST-OP, + STOMA
11. DIABETES
12. ENCOUNTER FOR + AFTERCARE + STATUS CODES
13. GALLBLADDER
14. GI TRACT
UGI Endoscopy
LGI Endoscopy
Endoscopy Coding Cheat Sheet
Colonoscopy Coding Flow Sheet
15. HERNIA + MESH
Hernia Coding Cheat Sheet
16. INFECTION + SEPSIS
17. KIDNEY / RENAL
18. LIVER
19. LYMPHATIC
20. NEOPLASMS: Primary
21. NEOPLASMS: Secondary
22. NEOPLASMS: Benign
23. NEOPLASMS: Uncertain Behavior
24. NEOPLASMS: PERSONAL + FAMILY HX
25. OBESITY, WEIGHT LOSS, MALNUTRITION
26. PANCREAS
27. PARATHYROID
28. SHOCK
29. SKIN + LIPOMAS
30. SPLEEN
31. THYROID
32. TRACH + BRONCH
33. TRAUMA + CHEST TUBES
Motor Vehicle Accident
Motorcycle Accident
Other Traffic / Pedestrian Accident
Fall, Slipping, Tripping, Stumbling
Head Injury
Assault
Chemicals In Blood
Thoracic Injuries
Fractures – Vertebral
Fractures – Facial / Base of Skull
Abdominal Organ Injury
Extremity Injury
Blood Vessel Injury
Trauma and Chest Tube Procedures
34. VASCULAR: C-LINES + PORTS
35. WOUND CARE + HYPERBARIC
36. UNLISTED CPT PROCEDURE CODES
37. APPENDIX A: Sheth’s EMR Best Practices
38. APPENDIX B: Initial, Subsequent, Sequela
39. APPENDIX C: Clinical Documentation Improvement
40. APPENDIX D: AMA CPT Coding Queries
41. APPENDIX E: Observation & Inpatient Status Coding