As a medical coder, I have learnt all the coding skills through practical knowledge. Here, I am just to share my experience of how to code a live medical record or chart. The beginners who want to pursue a career in medical coding will not be able to know about the coding skills. He or she may be CPC certified but the live or practical coding knowledge they will lack. Therefore, I might try to help you about different main points to check while coding a medical report. So, let take an example of below report, which we have to code.
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Sample Medical report for coding
NIVA BILATERAL LOWER EXTREMITY ANKLE ONLY:
INDICATION: Bilateral ankle ulcers.
TECHNIQUE: Bilateral brachial pressures and ankle segmental limb pressures, pulse volume recordings (PVRs), and ankle-brachial indices (ABIs) performed.
FINDINGS: PT ABI: RT: 1.18 LT: 1.16
PT Pressure: RT: 192 mmHg LT: 189 mmHg
DP ABI: RT: 1.17 LT: 1.12
DP Pressure: RT: 190 mmHg LT: 182 mmHg
Posterior tibial waveforms on the right are normal and markedly diminished on the left. Dorsalis pedis waveforms are also decreased in amplitude on the left. Pulse volume recordings at the ankle are relatively symmetrical and there is mild dampening of the great toe PPG on the right compared with the left.
IMPRESSION: 1. Diminished wave amplitude dorsalis pedis and posterior tibial arteries are continuous wave Doppler left side of uncertain clinical significance considering the normal ankle-brachial indices.
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Now as you can see there are different sides headers are there which I marked as bold. So, we check all of them one by one.
Different sections of Medical Report or Record
Exam header or title
The title of the exam tells us about the kind of exam or procedure by the physician has performed on the patient. So, when we see here in the above report, it says NIVA (Non-Invasive Vascular Assessment) exam is performed on the bilateral extremity. This exam has a particular CPT code, which is given at the end of the report. So, the title of the exam will give you the procedure code or the CPT code.
The indication in the medical report tells about the signs and symptoms for which the patient has come. Here you can see the patient has ankle ulcers, which can be coded as the diagnosis code in this medical report. The indication sometimes gives the clear picture about the diagnosis or disorder the patient has. For example, when a patient comes with a Flank pain, he or she will have some disorder related to retroperitoneal region (kidney or urinary bladder).
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The technique is the brief description of the exam title. The exam title or header will be given in Short but the technique will give you clear information of the kind of exam is performed. I always prefer to go with technique than to exam header or title. Some of the payers will not pay to physician if there is any discrepancy between exam header and technique. So, I would suggest do clearly check both the exam header and technique match each other and leads to same CPT code.
This is also considered an important part of the medical report. This section tells us about the kind of possible or confirmed abnormal things found during the exam. It tells them what the physician has observed while examining the particular organ or region. The report can tell everything is good or there are some abnormal finding present in the body.
This section is very important from diagnosis coding point of view. Why we say this because when we are heading towards the impression or rather I say conclusion, the physician will confirm about the diagnosis, found during the exam. The impression sometimes will use compatible or consistent phrases with the diseases or disorder. These phrases are mostly not considered as confirmed diagnosis in outpatient coding. So, only go for the confirmed diagnosis mentioned in the impression section.