How to research coding questions

June 1st, 2015 - Christina Benjamin

Categories: Billing CPT^® Coding Diagnosis Coding Evaluation & Management (E/M) HCPCS Coding

How to Research Answers to Coding Questions

Perform a search of the discussion board or listserv website prior to posting a new question. For your search terms, include specific words such as the diagnostic statement or procedure statement or the specific code number or the words “ICD-9 code” or “CPT® code.” Use quotation marks as necessary to limit your search further. This same searching technique can be applied to general Google searches as well. For Codapedia, the search box is clearly visible and oftentimes articles that are pertinent to hot topics are already posted and may have the answer that you are looking for. If you want to see an extensive list of the available articles in Codapedia, use the search term "Codapedia Editor." This brings up all the articles written by the original codapedia editors. Articles contributed by other specified individuals will not show up from this search.
If a search fails to reveal the specific information you are seeking, try posting a new question. Here are some tips for posting or asking a question.
1. Always remember that per HIPAA laws, no personally identifying patient information should be submitted via any forum or website. Also, be sure to read the terms or guidelines for the usage of the listserv or forum prior to posting your question. These guidelines also give you information on how to unsubscribe to the forum or listserv or discussion board if you wish negating the need to post a request to the whole forum to be unsubscribed. Also, the directions to unsubscribe are almost always at the bottom of every email that you receive from any listserv including Codapedia’s listserv.
2. It is also easy to make this mistake; you are in the middle of coding or billing and you have your CAPs lock on because the system requires it and then you run out to a forum and start typing in all caps without realizing it…it only takes a second to hit the caps lock button before typing the message and to hit it again when you are done and are back to your system that you were working in.
3. Subject line note: for a discussion board or listserv, be sure to post a descriptive subject line for your question and be sure to identify the most appropriate area of the board for the nature of your question. Don’t tag your question onto and older post that had nothing to do with your topic; change the subject line if the discussion topic changes within a thread or better yet start a new thread if possible. Keep all replies to any answers you receive on that same discussion thread instead of starting a new one so that others can follow the discussion. Often the discussion groups are divided by coding specialty or organized in some other way. Otherwise a descriptive subject line describes the nature of your question such as “coding knee arthroscopy.” Non-descriptive subject line examples include just listing “your name” or putting the term “coding question” or “CPT® coding help” or “Help” etc. You may have to repost your question or directly email one of the experts on the board who answers many of the questions if you don’t get a response after a few days.
4. It is recommended that you ask only one question at a time; multiple questions can be confusing and all of them may not be recognized by the colleague responding to you
5. It is recommended that you provide as much detail about the medical record documentation that you have when submitting your inquiry without providing any personally identifying patient information, of course. Such as an extensive excerpt of the operative note for a CPT® or ICD-9 procedure code.

It is recommended that you list the kind of payer involved, if possible or applicable
It is recommended that you list the state in which the provider and payer are located as each this can have an effect on the billing and coding rules and reporting requirements
It is recommended that you specify the setting for which you are coding or billing for (facility fees on the UB-04 or professional fees on the CMS 1500; inpatient—acute care or emergency department or skilled nursing facility, etc.)
It is recommended that you specify the type of coding guidance that you need (ICD-9 diagnosis code, ICD-9 procedure code, CPT® procedure code, both ICD-9 and CPT® procedure code, ICD-9 diagnosis code and CPT® procedure code, etc.)

Remember that the advice given by anyone other than by an official source is not to be considered authoritative or legal. It is given only as a professional opinion and you are solely responsible for final code assignment and other reimbursement-related decisions. Here are some tips on how to evaluate answers you may be given.

Don’t just take the answer; think it through and carefully evaluate it!
Note whether the response included official references or is consistent with basic coding rules/guidelines or whether it was simply an opinion, from experience, insurance specific, facility policy specific answer
If necessary, do further research and ask other sources. Nothing is wrong with getting a second or more opinion. As you gain experience with different sources, you will be able to determine what the best sources are. Don’t be afraid to professionally (not critically) challenge any advice given with further questions.
Use your gut! Learn to fine tune your personal judgment skills and to constantly reevaluate advice you have received on confusing coding issues. This is a sort of safety measure to catch anything inaccurate or faulty that you may have inadvertently picked up along the way and it will help to improve confidence in your own judgment.
It is my personal practice to make computerized notes of many of the answers I have received along with any references given for these answers. It is important to have a separate electronic personal file that you can keep with you so that you can readily search the file in the future if the question comes up again. You can also review the entire file periodically for errors and to update it with any new information as it comes available. This electronic file will also help you to apply previous answers given to future questions when appropriate. The goal is to detect patterns and principles so that you can apply them for new situations.

###

Questions, comments?

If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.

Latest articles: (any category)

COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli

COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.

Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli

2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....

Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?
October 10th, 2023 - Aimee Wilcox

When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.

Accurately Reporting Signs and Symptoms with ICD-10-CM Codes
October 5th, 2023 - Aimee Wilcox

Coders often find themselves unsure of when to report a sign or symptom code documented in the medical record. Some coders find their organization has an EHR that requires a working diagnosis, which is usually a sign or symptom, be entered to order a test or diagnostic study or image. Understanding the guidelines surrounding when signs and symptoms should be reported is the first step in correct coding so let's take a look at some scenarios.

The 2024 ICD-10-CM Updates Include New Codes for Reporting Metabolic Disorders and Insulin Resistance
September 19th, 2023 - Aimee Wilcox

Diabetes is a chronic disease that just seems to consistently be increasing instead of improving resulting in a constant endeavor by medical researchers to identify causal effects and possible treatments. One underlying or precipitating condition that scientists have identified as a precipitating factor in the development of diabetes is insulin resistance, which is a known metabolic disorder. As data becomes available through claims reporting, additional code options become possible with ICD-10-CM.

Documenting and Reporting Postoperative Visits
September 12th, 2023 - Aimee Wilcox

Sometimes we receive questions regarding documentation requirements for specific codes or coding requirements and we respond with information and resources to support our answers. The following question was recently submitted: Are providers required to report postoperative services on claims using 99024, especially if there is no payment for that service? What documentation is required if you are reporting an unrelated Evaluation and Management (E/M) service by the same physician during the postoperative period?

Understanding Gastroesophageal Reflux Disease and ICD-10-CM Coding
August 22nd, 2023 - Aimee Wilcox

Gastroesophageal reflux disease or GERD for short, is a disease that impacts millions of Americans on a weekly basis. Symptoms are uncomfortable, as are some of the tests used to diagnose it, but understanding the disease, tests, and treatments helps us better understand how to code the disease using ICD-10-CM codes.