Practicode Question — How to Abstract a Medical Coding Case

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 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

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