Lecture Notes: Medical Coding Training Session

Presenter:

• Name: Kevin Vasiana
• Affiliation: Medical Coding Buddies, Medical Coding Institute

Introduction:

• Launched the Medical Coding Institute to provide continuing educational units (CEUs) for ongoing learning in medical coding.
• Long-term involvement in medical coding training and educational platforms since 2018.
• Recent slowdown in live events due to work commitments as an adjunct instructor at Bryant and Stratton College, New York.
• Encourages community growth, with over 5000 people currently on the platform.

Educational Platform Goals:

• Offer hands-on training, but some limitations due to copyright issues with 3M products.
• No PowerPoint presentations as 3M content is heavily copyrighted.
• Training focuses on practical use rather than theoretical content.

3M Encoder & Epic Training:

• 3M Encoder used extensively in medical coding; integrates with patient charts.
• Automatic data integration with medical records, eliminating manual data entry.
• Epic requires certification and job-specific training; cannot provide broad-based training due to restrictions.

Hands-On Training Elements:

• Walkthrough of encoder functionality, covering demographic data pull and diagnosis input.
• Input of discharge status varies by entity and may require manual entry.
• Discussion on admitting and consulting physicians’ roles in diagnosis and treatment.

Coding Process:

• DRG Finder: Used for inpatient settings.
  • Important for driving reimbursement.
  • DRG is determined by principal diagnosis, discharge status, length of stay, age, and gender.
• APC Finder: Used for outpatient settings.
  • Different billing forms: UB04 and CMS 1500.
  • Capture charges through charge capture sheets.

Coding Clinics & CPT Assistant:

• Coding clinics provide authoritative guidance on complex coding issues.
• CPT Assistant acts similarly for procedural codes.
• Both resources are essential for ongoing coding education and staying current with coding practices.

Importance of Accurate Coding:

• Inpatient and outpatient coding differences highlighted.
• Emphasis on the significance of accurate code application for reimbursement.
• Role of CDI (Clinical Documentation Improvement) in querying physicians and improving documentation.

Productivity and Software Insights:

• Importance of understanding the software (e.g., Optum CSC, Epic) used by the entity for coding.
• Inquiry about productivity rates and software during the recruitment process to align expectations.

Practical Coding Session:

• Hands-on coding examples demonstrated using the encoder software.
• Tips for efficient navigation and diagnosis input in coding software.
• Overview of coding scenarios, including respiratory conditions and procedural codes.

Conclusion:

• Encouragement to participate in upcoming sessions and expand coding knowledge.
• Continuous learning emphasized through workshops and community engagement.