Code for the Day: Getting Through the Operative Report without Crying Part 2 (R45.83)

Every once in awhile I get a complimentary email or message about a blog posting from a couple of years ago, "Getting Through an Operative Report - Without Crying."  It's always great to hear that people are reading my blog.  It's even better when people cite a particular posting and tell me how very helpful it was for them. This posting has been speaking to me lately too as I move beyond the shallow end of the ICD-10 coding pool and immerse myself neck deep in this new and strange coding world.  I'm not sure if this will make people feel better or if I risk losing part of my audience with this admission, but I've been crying a lot lately when it comes to ICD-10-PCS coding.

And thus, the code for the day:

• R45.83, Excessive crying of child, adolescent or adult

To say that ICD-10-PCS coding is foreign is an understatement.  My favorite statement about it - which I'm sure I've already blogged about before - is that ICD-10-PCS is like CPT on steroids.  Even the most experienced coders struggle with it and I've had my share of debates with colleagues about how to code something. And yes, there have been tears.

But the tears have not overshadowed the sheer excitement of learning this new coding system.  I find that I'm learning more about how procedures are performed and it's honing my coding skills further.  But there are a few things I really have a hard time with.

• The concept of root operation is a tough one.  Trying to determine the intent of a procedure is harder than it seems.  So many things we take for granted in ICD-9-CM will be so different in ICD-10-PCS.  Case in point: when you replace a device in ICD-9-CM, you will likely find that procedure indexed under the main term "Replacement."  In ICD-10-PCS, the root operation Replacement is only used to describe replacing a body part with a device.  When a device is replaced, it's usually two separate root operations: Removal and Insertion.
• Determining the approach is not something to take for granted.  How a physician approaches a procedure is easy, right?   We know laparoscopic versus open.  We understand that that there are certain body parts you can get to through an orifice while others can be access percutaneously by puncture.  But approach is more complex than you think.  For a transbronchial biopsy, the scope is placed through a natural orifice, but once inside the bronchus, a percutaneous puncture is made to obtain the biopsy, so the approach is percutaneous endoscopic.  The really unfortunate thing here is that many coders don't realize they are making mistakes with approach because it seems so darn easy!
• There's no such thing as unbundling in PCS.  Having coded both ICD-9-CM and CPT procedures, I strongly believe that CPT coding is a great prep for learning PCS.  The level of detail needed to code CPT is much greater than that needed for ICD-9-CM procedural coding.  But there are times when I initially miss PCS codes because I am applying CPT bundling rules to PCS.  In short, you can't do that.  We have specific PCS coding guidelines - if you have procedures that have more than one approach, root operation, or body part as defined in the PCS table, you code multiple codes.  And for a CPT coder, that's sometimes hard.  A specific example - we have a PCS guideline that says if they biopsy a structure and then remove it, you code two procedures since it is two root operations: Excision and Resection.  Weird, huh?!
• Where is the class on procedures?  We've been hearing for years that coders need to bone up on the biomedical sciences including medical terminology and anatomy and physiology, but I'm finding that many coders can't figure out the root operation because they don't understand the procedures themselves.  And while the training I've been working on does go into detail about how procedures are performed, I find there isn't really a college course you can take on procedures.  But YouTube has some great videos if you want to self study.

Okay, so that's the bad news.  PCS is hard.  Really hard.  The good news is this.  It's fun.  Super fun!  And it's opened up dialogue with other coders I haven't had the chance to have in a long time and I miss that.  So if you're starting to learn PCS and you're struggling -maybe even crying - you aren't alone.  And the best news of all is that they make some really cute tissue boxes these days!

Getting Through an Operative Report - Without Crying

One of the things I love about the mentoring I do for students is it reminds me of what it was like to be a newbie. And I don't just mean the excitement of being on the cusp of a new career. I am also grateful to be humbled and reminded that I knew absolutely nothing when I got started. These days when I stand in front of an audience of coders or students and teach the latest and greatest on whatever topic I'm discussing for that day, it's the culmination of years of experience and hours (or weeks) of research and preparation. But you might be interested to know that in my first coding job I did come home from work on more than one occasion in tears.

I can't explain that helpless feeling when you've trained so hard - and studied and taken numerous tests and graduated, etc. etc. etc. - and you land that first job and they hand you an operative report. And you freeze. Because it's like Greek. You have no idea what to do. Where are the short coding scenarios you learned in school? What does that first paragraph really say? You know you could find the code if you could just figure out what the heck the darn report says (incidentally, I now consider myself trilingual: English, medical terminology, and coding!). You know you're qualified, but are you really?

So I sometimes forget when I'm working with new students what it was like. Of course, there are still days when I feel like crying because I keep getting myself into uncharted territory. I actually relish researching and "figuring out" things that other people may abandon because they are too foreign or "difficult." But it wasn't always that way. I used to be an overconfident novice coder who, when a chart was placed in front of her, did a lot of tap dancing to make it look like she was competent. The good news is, 15 years later, I feel competent (most of the time anyway!).

The Word Search
I've worked in coding education now for about 8 years. In that time I've been asked to work on a lot of different projects related to coding education. In addition to training coders, I've been asked to evaluate people to see if they would make good coders. And I always start with the word search test. Do you like word searches? If not, you might want to consider a different career. Because coding is one big word search. You have to decipher the medical record (or operative report) and decide which words are important and which ones you can ditch.

Bunionectomies are a Kick
The first time I was given a bunionectomy report to code, I'm pretty sure I cried. After all, the procedure title was something like "Mitchell-Chevron," which meant nothing to me. And I knew enough about coding to know I had to read the report to figure out if it really was a Mitchell-Chevron. And the report was surely about 4 pages - pretty standard for a thorough podiatrist. And when I went to a class to learn how to code bunionectomy procedures, I realized that out of the entire 4 pages, I focused on about 3 sentences. That was it. The rest was coding garbage. In case you're wondering, a Mitchell-Chevron bunionectomy involves removing the medial eminence (AKA bunion) and making an osteotomy (bone cut) into the first metatarsal (the foot bone connected to the big toe). I'm still amazed that it takes 4 pages to describe that.

Deciphering the Operative Report
I am often asked to explain how to decipher an operative report. Well, it depends on the procedure, really. And if you are a new coder and you ever have the opportunity to go to a seminar where they will present case studies, this is the best way to learn. I've taught dozens of classes and nothing drives home my point more than walking through the cases and coding them. But I will give you some basic elements here to get you started. While these rules don't apply to all specialties (e.g., interventional radiology has "special" rules that drive the even the most experienced coders - that would be me - batty!), this should get you started on some of those basic surgical reports.

• Rule 1 - Doctors Lie: Admit it, you watch House and have heard him say on more than one occasion that patients lie. Well, Dr. House, I would like to point out that doctors lie too. They will state the procedure one way in the title and then proceed to describe a completely different procedure in the body of the report. For example, the doctor may state a left heart catheterization was done, but after reviewing the report, the catheter never made it all the way to the heart - only to the coronary arteries. So keeping this in mind, you should never believe what you read in the procedure title. Honestly, I rarely even read the procedure title anymore - it's often fiction. As for Dr. House, I would love to see a strong-willed coder have it out with him on the show about his documentation, which I'm sure is a mess.
  

• Rule 2 - Get a Medical Dictionary: There's no excuse anymore. When I learned how to code, we were still using Windows 3.1, so there was no way the hospital was using the internet. But even without online resources, I had a medical dictionary on my shelf. And it was used often. How will you know if something is important if you don't even know what it means? While you're at it, make sure you also have access to an English dictionary. I know it's a novelty, but you will also find complex nonmedical words in the operative report (or even in your code descriptions). If you don't know what it means, look it up. Tedious, I know, but you will learn. Of course, you might feel like Billie Dawn from Born Yesterday, but you will learn. (Don't understand the movie reference? Look it up!).

• Rule 3 - Just Like Ragu, It's Probably in There: In school we hear terms like "it's bundled" or "separate procedure" but what does that really mean? Well, it means it's integral to the main procedure and don't code it out separate. What's included? Well, pretty much anything that has to be done in order to accomplish the main procedure. Taking out an appendix? Well, then the incision (or creation of ports for laparascopic instruments) is included. So is the closure at the end of the procedure. I don't know about you, but if I have my appendix taken out I sure hope the physician remembers to suture me closed at the end. All those things are like regular ingredients in Ragu pasta sauce - tomatoes, oregano, garlic. It's in there! So don't code each component out separately. Now, had they decided to do a liver biopsy while in there, that's different. That's like throwing a banana in the pasta sauce. So it gets coded separately.
  

• Rule 4 - You Will Only Use 10-20% of the Operative Report: Don't feel like you need to use every word in the operative report to code the case. The fact is, the operative report isn't about you, it's about the patient and it's a communication tool for clinicians. It just happens to double nicely as a recording of everything that happened to the patient and can substantiate coding and billing. It's up to you to determine what's important in the documentation. There's a reason we use coding for billing - your codes actually fit on a 1-page claim form so the insurance company doesn't have to read through every single medical record.
  

• Rule 5 - Know the Procedure: Okay, maybe I should have led off with that one. Medical terminology is, quite literally a foreign language. In fact, it's at least two foreign languages: Latin and Greek. So when you say "it's Greek to me," you're being quite literal. A really good medical terminology class will solve a lot of problems. You may think esophagogastroduodenoscopy is a really big word until you break it down and realize it's visualization (scopy) of the esophagus (esophago), stomach (gastric), and part of the small intestine (duodeno). You also need to know your anatomy. You need to know when they operate on a structure that's part of a bigger structure (e.g., mesentary of the intestines) vs. a different organ altogether (like in the appendix/liver example above). After you learn medical terminology and anatomy and physiology, that's half the battle. The rest of the battle can typically be solved with Google. Come to think of it, there are few things that can't be solved with Google. I'm pretty sure there will be a support group some day for Google-aholics, but in the mean time, I highly encourage you to google a procedure if you don't know what it is. I never remember what a Whipple procedure is. But I can google it in about 10 seconds. Just be careful which website you select from your Google search list - something from the Mayo Clinic is probably more reliable than lazy-Dan-explains-medical-procedures.com.

• Rule 6 - There is Crying in Coding, Just Don't Let Anyone See It: Oh, how I wish I could tell you I had that one down. But I'm pretty transparent when it comes to being frustrated. And I've had students cry in frustration when trying to code case studies. But try to minimize your public displays of tearful frustration and remember this - we've all been there and this is hard. It's okay to not know all the answers all the time.
  

I hope this at least gets you moving in the right direction. When people ask me how I learned everything I know I, 1) laugh, because I know there is so much more for me to learn, and 2) tell them how the rules above worked for me.