if you've heard about medical coding and you're not quite sure what it is stick around for this video because today i'm going to discuss the introduction to medical coding [Music] [Applause] [Music] hey i'm victoria i'm a medical coder auditor educator i've been in this industry for over a decade and i've published lots of articles and had national speaking engagements on medical coding and today i want to talk to you about the introduction to medical coding so what is it what kind of stuff does medical coders do and what are the jobs of medical coders a medical coder is someone who translates medical records and medical charts into codes mostly for diagnoses and services that were provided in medical coding there is cpt which is current procedural terminology so those are codes for a lot of procedures and services provided to patients then there is icd the international classification of diseases and we use the cm which is the clinical modification and then in the inpatient and facility they use pcs the procedural clothing system hitpix is the healthcare common procedural coding system and it contains a lot of codes for things like drugs or durable medical equipment there's a lot of tools that you can use online and through electronic medical records that will help you select the right code but most coders prefer to use their tried and true coding books so here is your hit picks i have an icd-10-cm i don't do inpatient coding so i don't have a pcs book and then the cpt book for your procedural coding medical coders use their electronic medical records to review charts and then assign the right codes that are in their code books even though there are electronic lookup tools in order to sit for any medical coding certification exams which are needed to become a medical coder and work as a medical coder you need to have the paper books you have to have the paper books to test for there are two main entities that employers trust for certification of their medical coders and that's aapc and ahima those are our big brands i say that they're the coke and pepsi of the medical coding world those are the ones we can we know and we trust aapc does mostly coding for provider-based services so things that are done by physicians and physician extenders and then ahima is more known for inpatient coding so coding for the hospital coding for the room and board and all the services that you receive in the hospital as an inpatient now there's lots of other certifications out there a lot of technical schools will offer a discounted or even free certification for the cbcs through the nha and nothing against that credential but it's really not what's in demand by employers there's a lot of different places that medical coders could work they could work just in a billing office or they could work in a physician office or a hospital a surgical center nursing care the emergency department insurance offices they could work for the government or for an ambulance service they could work for dme suppliers or they could even work for dental services although those type tends to use a little bit of a different type of coding the cdt which is the current dental terminology now if you want to know about the typical day of a medical coder i do have a video for that i'll link it up and the card above and i'll also link it in the description below and i also have a video you might want to check out as far as skills that are beneficial to the medical coder and a video on if medical coding is right for you medical coding does require a lot of reading of reports and reading of medical records and then using your tools to translate them into code it also requires a lot of understanding of complex guidelines not just coding guidelines but sometimes insurance federal state and government guidelines in order to be a successful medical coder you have to know how to not only navigate those systems but your coding books there are lots of very complex coding guidelines insurance guidelines and even government guidelines on the federal and both state level there seems to be almost a misunderstanding that these medical coding books are basically like dictionaries or phone books that you just look up a diagnosis or a procedure and you just slap on a code and there's really so much more than that let's look at even a simple example so here's a fairly simple case example this patient has a perinekia of the left index finger so this is why you need to know medical terminology because you need to know what a perinecia is in order to assign the correct code for it perineke is when you get that little uh infected cyst on the like a hangnail and stuff on your finger after the area was anesthetized i then prepped this area with bentatine solution then was prepped in a sterile fashion utilizing iris scissors i then opened up the area of pus and tried to express any pus that was in that area there was no evidence of felon septic arthritis or obvious retained foreign body i then cleaned out the area as best as i could and there was a dressing that was placed the patient tolerated the procedure well patient was giving instructions to keep the area clean and to continue a neosporin and band-aid for a couple of days and return immediately if the condition worsens as we discussed so this um this where he says he opened up the area and expressed all the pus that's what we call an incision and drainage so an ind so when we would be looking up the cpt code the procedural code for this we would likely look under if you're just learning coding you look under the alphabetic index in the back i would just go to the integumentary system but for the sake of this demonstration i'm going to show you what you would do when you're just learning is look for the word drainage here in the index and under drainage we have abscess and then here we have perinekia and that's 1 0 0 6 0 1 6 so that's where we go in our code listing here in the front so our integumentary one zero zero one zero zero one zero zero one zero zero six zero is incision and drainage of abscess carbonyl supportive hydrogen ions cutaneous or subcutaneous abscess cyst for uncle or perennicia simple or single and then the one with six one is complicated or multiple and this wasn't really complicated he said there wasn't any kind of arthritis felon it didn't look like there's complex closure or anything like that involved so we would go with this simple code of one zero zero six zero i apologize i have terrible handwriting these are zeros next we need to figure out our diagnosis code so the diagnosis code for perinekia so we start with our alphabetic index under p and go to perinekia p-a-r oh parkinson's pear right there uh see also cellulitis digit okay so now we're not at the right code here it's telling us to go somewhere else it says c cellulitis digit okay so we go and see cellulitis digit over to our c's cellulitis of the digit finger c cellulitis finger so the latest finger l03.01 and then it wants us to put on um an additional digit l03 0.01 and then we always have to double check our diagnosis codes from the alphabetic index in our tabular list so we go to lo3 zero one cellulitis of the finger and once at a right left or unspecified this one here it says left the sixth digit that we need is the two for the left finger so that would be our total code so this is what we would bill out the one zero zero six zero for the incision and drainage of the perinekia and then for the perinekia itself l zero three point zero one two so while that one wasn't too hard let's look at something a little bit more complex so here we have a case and i'm not going to code this out but i just want to show you for complexity purposes that this is a case that is a thromboendartectomy of right common external and internal carotid artery using internal shunt and dacron patch angioplasty closure coronary artery bypass grafting times three utilizing left internal mammary artery to the left anterior descending and reverse autogenic saphenous vein graft to the obtuse marginal posterior descending branch of the right coronary artery so you can see again medical terminology understanding what you're looking at is extremely important and this is a very complicated case and when you're working in coding you can't just decide you're going to eat this case and not do it because it has to get done and there is no going oh this is too hard i'm just going to skip it if you're a medical coder there's no skipping of cases it's your job to code it regardless of how complicated it might be or how many times you might have to go back to that provider to ask for clarification on what was done so i hope that was a helpful introduction to medical coding if you think so make sure you give this video a big thumbs up and don't forget to subscribe and hit that notification bell because you're going to want to get alerts because i'm posting videos twice a week i will see you in the next video and until then just keep on coding on [Music]