Getting to Know the Practicode Case Example


Alicia: We’re going to do a Practicode case.
This is one that stumps a lot of people. Laureen: Alicia, before you get started, for
those that don’t know, can you briefly explain what Practicode is? Alicia: Practicode is a company that offers
a service with real redacted scenarios or cases or encounters. So, they’re multispecialty
and there’s about approximately a 100 to 150, sometimes more, individual encounters
in these specialties. Anything from cardiology to gastroenterology to family practice and
fee-for-service and ICD-9, ICD-10; so we offer this as an additional course that students
can take where they’re wanting real life experience. This isn’t necessarily a good
thing to go through if you haven’t tested for the CPC, this is meant to help you really
work on specialties and abstracting of real cases, not scenarios that were created to
drive home a guideline. So, if you think you want to do cardiology or something, then this
is going to help you. Laureen: So, you get certified and now you’re
working hard to getting that first job. This is a perfect thing to do in that gap to get
your speed up, and here’s an example of one of the cases. By the way, Alicia conducts
a support call every Thursday night when we’re not doing this call, and she has all of the
MCP, that’s our medical coding practicum students on the first hour, then the coding
students the second hour, and our Blitz customers the last half hour. She goes over a lot of
these cases and really the students get a lot out of it. Alicia: Practicode is a company that offers
a service with real redacted scenarios or cases or encounters. So, they’re multispecialty
and there’s about approximately a 100 to 150, sometimes more, individual encounters
in these specialties. Anything from cardiology to gastroenterology to family practice and
fee-for-service and ICD-9, ICD-10; so we offer this as an additional course that students
can take where they’re wanting real life experience. This isn’t necessarily a good
thing to go through if you haven’t tested for the CPC, this is meant to help you really
work on specialties and abstracting of real cases, not scenarios that were created to
drive home a guideline. So, if you think you want to do cardiology or something, then this
is going to help you. Laureen: So, you get certified and now you’re
working hard to getting that first job. This is a perfect thing to do in that gap to get
your speed up, and here’s an example of one of the cases. By the way, Alicia conducts
a support call every Thursday night when we’re not doing this call, and she has all of the
MCP, that’s our medical coding practicum students on the first hour, then the coding
students the second hour, and our Blitz customers the last half hour. She goes over a lot of
these cases and really the students get a lot out of it.
The first thing we’re going to look at is: what is his chief complaint, his chief concern?
Now we know he’s here for a hospital follow up. The next thing I like to do is scroll
down to the bottom of the document and this is kind of the auditing and risk adjustment
part of me. I always check to make sure there is a good signature. We’ve got electronically
signed by our doctor with a credential and a date. A real electronic signature would
also have a timestamp on there. Then I want to look and see, what does he
say is the diagnosis? That will just be right above there. It’s usually Diagnosis or Assessment.
In this assessment, it says lower extremity swelling secondary to post-CABG. Right there,
we know he came in for a follow up, but this is the diagnosis that he’s given and this
is what he plans to do to treat it. Now that we know what’s going on, we’re
going to go back up to the top and let’s look at the HPI or the History of the Present
Illness and find out if that’s the only thing going on. Go to the Problem List, this
one is set up a little bit different. They listed the Problem List first. Now, keep in
mind we know that they’re there for a hospital follow up, so that could be several diagnoses.
We know what was in the Assessment. Keep in mind also, lots of things to keep in mind,
what type of coding are you doing? If you’re doing risk adjustment, it’s a whole different
set of things you’re looking at versus coding this for the office. A problem list is often copied and pasted.
You don’t really want to code off a problem list because it can have things that are outdated,
but it shows a continuum of care of what’s going on with this patient, so it’s important
that we need to look at it. We have more information. We know what type of a CABG this patient had.
We know the reason was an abnormal EKG. Then, the other things, we know he’s five years
status post prostate cancer. He has hyperlipidemia and he has vertigo, secondary to labyrinthine
disorder. Now, we also want to know, what did he come
in for? This is being coded for just a regular doctor’s office. This isn’t risk adjustment
or anything else. We know he came for a hospital follow up, why was he in the hospital, and
it tells us right there because he had a CABG and then there was some problems and he an
abnormal EKG. Where this trips you up, is that we’re not
concerned about the other problem list. We’re concerned about why he was seen for this encounter.
Now, there are things that can be applicable to that, but what is the focus in the diagnoses
that we’re given? We look at the allergies. Man, not really
a big deal. Medications are very, very important. It lets you know what’s going on, and sometimes
they’ll even be dates off to the side. If you don’t know what a medication is, you
need to go look it up even if it’s in a Medication List and it’s not applicable
to maybe your diagnosis. But if you see this diphenhydramine, what in the world is diphenhydramine?
Go to, like, www.drugs.com. Google it, it’s Benadryl. If you don’t know that, you need
to know. The
other medications that will jump out, we know
that they’re on potassium, that’s the KCl. They’re on potassium because they’re
on furosemide, which is a water pill. Things like that. So it lets you know what’s going
on. Now we’re going to look at the History and
they’re going to tell us what he actually did for the patient. The patient is here for
a follow up. The EKG was off, he had a bypass. If we look at the date, this is all like within
the same day or something. Then, he had no chest wound complications. He presented to
the office a week ago. Everything in there, as I’m scanning, really says that he has
a problem. His legs remain swollen, worse after sitting for 30 minutes… and it’s
even getting swollen while he’s sitting there. No fevers, no other reason for the
cause. Now we’re going to look at the Physical
Examination. Right now I’m going to focus on diagnosis. I always like doing diagnosis
first because I like the diagnosis part of it. We’ll just do that first. We’ll worry
about the E/M later. So now this is where you’re going to really pull the E/M stuff.
The previous stuff is what the patient is telling, the HPI. He’s saying, “These
are my problems” and the doctor will ask questions, like, what makes it better, what
makes it worse? But these are the questions the physician is asking and the patient is
telling. Then, when you get to the Physical Exam, this
is when the doctor is actually putting their hands on the patient. This is what the doctor
observes, not what he’s being told, but what he is coming to a conclusion with. So
it’s two separate parts. This is very, very important so you want to scan this and look
to see if you have anything that jumps out. This is where you’ll see a lot of things
that you say “negative” or “no” but we know that he has a problem with his extremities. His cardiovascular, that all looks good, except
for – isn’t that funny that it says, and this is where they get into copy and pasting
and you can tell he messed up on this because we know his legs were swelling while he was
sitting there. It says, “No murmur or clicks… Femoral, tibial, dorsalis pedis pulses intact.”
You got swelling; they want to know is it cutting circulation? “No leg swelling.”
That’s a copy and paste because right above that, it was swelling while he was sitting
there talking to doctor. Anyway, you got to be very careful about what you’re reading. The skin, it’s also where we’re going
to see some… this contradicts it. It says he has an incision. “Both legs are significantly
swollen, 3+. No weeping noted.” Now we’re talking about the integrity of the skin and
stuff like that. The Assessment: Lower extremity swelling secondary
to post-CABG; and the Plan. Now, let’s go look at the answers
that we’re given. These are the answers
that Practicode gave us and then these are the answers and I just drew this random first
from a student; but these are very common that get coded. One, they say it’s edema,
but nowhere in the document did the physician state that the patient had edema. He constantly
stated that he had swelling, swelling of the limbs. That is actually, you can see two different
diagnoses. Then, he’s status post-CABG. There’s a V code for that, that’s very
pertinent to his care. This is where you get into some funny things
where it’s not always black and white. It’s not edema, it is leg swelling. It may change
and become edema later, but he didn’t say edema and we can only code what he states.
He has hyperlipidemia, but that wasn’t in the assessment. Is it pertinent to his care
for what’s going on? Probably, but it’s not in his assessment. That’s why they didn’t
code it. And the history of the prostate malignancy – is that pertinent to his bypass and what
the follow-up is all about, what’s going on? No, not really. If you could make a case
that it’s part of the plan of care, but he didn’t address that, that was a problem
list. We can’t really code off a problem list.
We already saw in this document how copy and paste will get you in trouble. He said right
there that there was no leg swelling and then he turned around and said that there was leg
swelling, so you have to be very careful. If you’re ever in doubt about this, what
you do is you go query the physician. You ask him and say, “You said this was limb
swelling, is this edema?” If he says, “No. It’s not edema.” “OK, thank you very
much for clarifying that.” “Is his hyperlipidemia in any way pertinent to this?” “No, it
isn’t.” “Is the fact that he is status post prostate – could that have anything
to do with the swelling?” If he says, “Yes” then it’s pertinent. Then, you’re coding
that. Then, you have your leveling, your E/M, that’s
really in some part the easiest part. They did several tests, he did exams. You can click
off all of the little parts of doing the exam for an outpatient and that it’s an established
patient and it got a 99214, but for the most part, it was going to be a 99214. But that
right there is a little overview, that’s how we do it. If we have questions about certain things,
like, what’s the medication for hyperlipidemia? We go look it up while we’re doing this,
and we spend an hour doing 3 or 4 cases, sometimes we may only get through two because we break
it down, understand the disease process. We do the E/M leveling together and we kind of
joke about, so-and- so said it was a 214 and we picked the 213. It allows several people
with several backgrounds and levels of experience to work together as a team and see how other
people think. Unlike these Q&A webinars, it’s interactive, and we actually talk to each
other and you can get a lot of insight from the students and their backgrounds and their
experiences, so that’s a lot of fun. Laureen: How to tease it out. Get that information
out. Alicia: Exactly.

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