Spotlight on Certification: Certified Interventional Radiology Cardiovascular Coder (CIRCC®)

Lately I've heard a lot of buzz about the AAPC's credential, Certified Interventional Radiology Cardiovascular Coder (CIRCC).  Interventional radiology (IR) coders are in demand because of the complexity of the field and the notoriously high error rates seen on audits. It may sound like a great credential to get, but before you make any sudden movements, here's what you need to know about the CIRCC exam.

Why this credential exists
I've been coding now for 22 years and I've seen quite a bit.  I helped train the workforce in ICD-10-CM and ICD-10-PCS. I've audited ICD-9, ICD-10, CPT and HCPCS codes.  I've read the Federal Register on DRGs and APCs.  But the hardest thing I've ever had to learn to code is IR and cardiology.  The coding rules are complicated, ever changing, and often inconsistent for different parts of the body.  Learning how to code IR and cardiology procedures by just looking at the CPT book is tough enough, but not all the rules are written there.  There are other societies that develop suggested guidelines and then there are the payer's rules and interpretations.  In a hospital setting, an understanding of IR and cardiology coding also usually requires an understanding of hospital charging and how departments are credited revenue.  This credential exists to show that you've mastered these areas of coding.  In my mind, this is the most difficult area of coding there is.

This is not an entry-level credential
I took the CIRCC exam four years ago with about 10 years of experience under my belt.  It was a tough exam.  As a matter of fact, it was the hardest multiple choice exam I've ever taken and I would put it up there with the Certified Coding Specialist (CCS) test as one of the toughest.  If you are thinking you will get the CIRCC and then land a job as an IR coder without any experience, think again.  This is the test you take after you've been coding those types of cases for a long time and feel confident in your abilities.  AAPC recommends, but does not require, at least two years of coding experience before taking the CIRCC exam.

What's on the test
The CIRCC exam is spotlighted for its focus on IR coding, but it also includes cardiology procedures.  The procedures we're talking about are surgical-type procedures done in a radiology suite or cardiac cath lab using radiological (fluoroscopic) guidance.  For IR, this can be vascular studies (angiograms) and interventions (e.g., angioplasty, stenting, thrombectomy) or nonvascular procedures (e.g., placement of biliary stents, nephrostomies, and fluoroscopically-guided biopsies).  For cardiology, this can be diagnostic cardiac catheterization, angioplasty and stenting, and cardiac electrophysiology studies and arrhythmia ablations.   If you don't know what any of that means, I don't recommend taking the test until you learn more!

What it costs
At the time of this writing, the cost to sit for the CIRCC exam is $400.  But the cost of taking the CIRCC doesn't end when you register and pass the exam.  Like other credentials, you need continuing education units (CEUs) to maintain the certification.  But unlike most other AAPC credentials, there are limited vendors from which you can get those CEUs.  Before you decide to take the test, look at the CEU requirements and visit the vendor websites (the AAPC has links) to see how much your CEUs will cost you and be very realistic about what you can afford.  If your primary job is coding these types of cases, check with your employer to see if they will reimburse you for any of the costs.  This is an expensive credential to maintain, but if it's valued by your employer, they may cover the costs.

Read all about it
I could regurgitate the contents of the AAPC's website about the CIRCC exam, but instead of doing that, I will direct you to their website with this simple instruction: Do your homework!  There is a plethora of information on the AAPC's website for this exam and it will tell you everything you need to know from the breakdown of the exam questions, approved manuals and materials (yes, you can bring anatomy cards showing selective vascular ordering), certification requirements, history of the exam, and FAQs.  If you were going to spend $400 on a new smartphone, you would probably read up on the different models before making a final decision.  Why wouldn't you also do this for a credential?  Don't take this exam until you've read all the fine print.

Preparing for the exam
Once you decide that you're ready to pull the plug and take the test, it's time to prepare.  Even if you've coded these cases for a long time, there is still preparation to be done.  Here is my list of recommendations:

• Get the right CPT book.  The AAPC's website is very clear that they will only allow you to use the American Medical Association's (AMA) version of CPT.  If you have a CPT book from any other publisher, you cannot use it.  I recommend the AMA's Professional Edition of CPT for its color coding and pictures.  It's more expensive than the standard edition, but I think it's worth the money.
• Mark your CPT book.  Don't waste time writing in the things you already know, but I do recommend making cross-reference notes for any codes that have a one-to-one relationship.  For example, I wrote all of the C codes for drug-eluting stent placements next to their CPT counterparts so I didn't have to open another book during the test.  Sometimes CPT includes instructional notes in the Surgical section directing you to the Radiology component code.  And sometimes it doesn't, so I wrote those in too.  Especially if you are used to using an encoder, make sure you have your book set up so you can flip to different code sections fast.
• Get the exam prep book.  Yes, it costs more money and no, I am not being paid by the AAPC to push their products!  The exam prep book will go over what's on the test.  It will give you practice questions and show you the type of questions that will be on the exam.  The one thing I remember from the exam prep book is it said in several places that none of the questions are meant to be trick questions.  That might sound like a no-brainer, but when you really get into IR coding, you'll see why that's an important thing to remember.
• Spend your study time on your weak areas.  Don't waste your time studying things you already know.  If there is an area that is not your strongest, make notes on those CPT sections and find tricks to help you remember.  When I took the test, I was strong in vascular IR and cardiology, but not so much on nonvascular IR, so those sections of my book had the most notes.  Remember: you can write notes in your CPT book, you just can't put any loose pieces of paper in them.  
• Take a prep class.  If you can find a class that will cover part or all of the exam content, enroll now.  I am teaching a vascular interventional radiology class in October 2017 in Denver, which covers some of the trickiest IR coding.  I would love to see you there and chat about your CIRCC aspirations!

If you've ever considered taking the CIRCC exam, I hope you found this post useful.  Want to learn more about IR coding?  Stay tuned - more posts to come!

Two Track Mind: ICD-10 and Vascular CPT Coding

Do I seem like a stranger? Because I feel like a stranger. These days I have two things on my mind: ICD-10 and the CPT coding changes for vascular procedures. And pretty much anything outside of these two topics isn't getting much of my attention lately - including blogging. So in an effort to provide you with a recent blog post - and to keep my attention focused on the tasks at hand - I figured I would blog about what I've been up to recently. This will give some insight into the challenges that existing coding professionals are facing today.

Before I let you in on what's been on my plate, I should mention that there is no crossover between these two topics. They are two very different aspects of coding that use two entirely different parts of the human brain. Or at least, they use two very different parts of my brain! When asked why I am so deeply involved in two areas that are so vastly different, all I can say is, I love a challenge. And challenged I've been!

CPT Code Changes

I know what you're thinking. "It's March, Kristi, the CPT code changes were effective January 1 so that's old news." Well, the reality is, it takes some time to get used to new codes. Since I spend a significant amount of time as a subject matter expert (SME) for my clients in the realm of cardiac catheterization and peripheral vascular interventional radiology coding and charging, I can tell you that 2011 has presented my clients with some significant challenges. First of all - the deletion and nearly complete overhaul of the cardiac catheterization section of CPT. If you have a chance to look at a 2011 CPT codebook (I recommend the Professional Edition since it shows all code changes in color-coded fashion), and compare it to a 2010 book, you'll see what I mean.

My biggest challenge? They changed the code descriptions and code numbers, but in many cases used the same digits - just in a different order. A dyslexic's nightmare and yes, yours truly is dyslexic. There are a couple of perks now - we no longer have to worry about coding left ventriculography separately, it's bundled into the left heart catheterization code, and for the most part, supervision and interpretation (S&I) codes are a thing of the past.

The peripheral vascular coding is getting really interesting. This year the American Medical Association (AMA) decided that leg revascularization procedures could be more effectively reported using bundled codes. This new Wal-Mart approach to coding is becoming more commonplace in interventional radiology (IR) coding. What do I mean about Wal-Mart codes? Well, vascular IR coding has historically involved the separate reporting of all procedure codes, including the catheterization or approach, which is typically a no-no in coding. The end result is often a list of 4 or 5 codes to describe one procedure. Wal-Mart coding is "one stop shopping" where everything is included in a single code. Maybe I should call them Ragu codes for those who remember the old Ragu pasta sauce commercials. You know - "It's in there!" This Wal-Mart or Ragu concept of coding means unlearning many complex IR coding guidelines that have been ingrained in our brains over the past few years.

The new leg revascularization codes are set up based on a heirarchy - angioplasty followed by atherectomy followed by stenting - with newly established vascular territories. The iliac territory consists of three vessels. The femoral-popliteal territory is treated as a single vessel. And the tibioperoneal territory as three vessels. To make things more confusing, the AMA deleted all of the atherectomy codes from Category I in CPT and moved them to Category III.

And because IR is arguably the most difficult area of CPT coding (as an IR SME I may be biased), someone has to research all this and educate coders on the changes. Thus, I find myself updating training materials with these changes and presenting the changes. If the areas of cardiac catheterization and IR interest you, I suggest you acquire a solid foundation on basic medical coding first. These 2 areas are difficult for even the most seasoned coders.

ICD-10-CM and ICD-10-PCS

Well if you're a coder, a coding student, or have done any research at all about the coding field, you know we're in for a huge change with the implementation of ICD-10-CM and ICD-10-PCS in 2013. I would like to say that all organizations are in full swing and getting ready for the transition. What I'm hearing as I talk with organizations, though, is that they are just getting started - a full 1-2 years behind the recommended schedule.

In recent weeks I've taken my ICD-10-CM/PCS trainer recertification through AHIMA and kicked off a Task Force through the Colorado Health Information Management Association (CHIMA). As chairperson of the ICD-10 Task Force here in Colorado, I've had the chance to meet with providers and organizations who will be impacted by the ICD-10 code sets. And I am also embarking on a project through AHIMA to get ensure that Colorado Medicaid is ready for the transition.

In addition to that, I'm preparing presentations for the spring conference season and developing ICD-10 tools and training programs for my company. Here's a shameless plug for The Wilshire Group - just in case you're looking for some additional ICD-10 references! My favorite part is the ICD-10 countdown. I've set this as one of my home pages so I can feel the urgency every time I open my browser!

Prepare for Your Challenge

If you really have a passion for coding, then this commentary got you really excited to learn more. I wish I could properly convey how much more difficult coding is than simply looking up a code in a book. And I wish you could get an accurate depiction of what your daily work will look like as a coder. But the truth is, you don't really "get it" until you get into it and although I know so many are frustrated because they can't get the required experience to get hired, I've said it time and again - keep trying to find an angle to get the experience you need to get your foot in the door. And once you're in, I hope you're ready for the challenge because it's a constant learning experience.

It's Coding Season!

I'm sometimes asked if there's a busy time of year for coders or if it's pretty much status quo. As a matter of fact, there is a busy time of year for coders and this is it!

Every year, we gear up for all the upcoming year's coding changes. That means letting coders know which codes have been deleted, expanded, and added and letting coders, physicians, administrators, and revenue cycle personnel know how code-based reimbursement will be affected in the coming year. This may seem rather straightforward, but since we work with more than one code set with different implementation dates, fourth quarter of each year can be pretty crazy!

ICD-9-CM Codes
The ICD-9-CM diagnosis and procedure codes are updated annually with the Center for Medicare and Medicaid Services' (CMS) fiscal year (FY), which begins October 1. These codes are used to report diagnoses for all health care settings and procedures for hospital inpatients. Right now, you will find coders acquiring their FY 2011 ICD-9-CM code books and attending seminars on the code updates. Some of this year's highlights include:

Diagnosis Codes:

• A new code for obesity hypoventilation syndrome
• Expansion of fluid overload code to differentiate between transfusion-associated fluid overload and other causes
  
• Expansion of the avian flu codes to include manifestations of the disease
• Expansion of the blood transfusion incompatibility codes to differentiate between ABO and Rh incompatibility
• Additional personal history codes
• Expansion of the body mass index (BMI) codes up to allow for classification of BMI in varying increments up to 70 and over
• A new section of V codes to report retained foreign body fragments
• A new section of V codes to report the number of placentae associated with multiple fetal gestations

ICD-9-CM diagnosis codes are within the public domain and the 2011 revisions can be found on the National Center for Health Statistics' (NCHS) website.

Procedure Codes:

• New code for placement of a central venous catheter under imaging guidance
• New codes for carotid sinus stimulation components and devices

Changes to the ICD-9-CM procedure codes are within the public domain and are available on CMS' website.

IPPS and MS-DRGs
The inpatient prospective payment system (IPPS), the system used for Medicare payments for inpatient hospitalizations, is also updated each year on October 1. This includes recalibration of the relative weights for the classification system used under IPPS - the Medicare severity diagnosis related groups (MS-DRGs). This year, the major changes to the MS-DRGs include:

• A documentation and coding adjustment of -2.9%, wherein CMS will discount payments in FY 2011 to hospitals by 2.9% in order to remain budget neutral. The attempt to remain budget neutral is to counteract the financial impact of implementing a severity-based DRG system 3 years ago.
• The addition of 12 new quality measures to be reported by hospitals under the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program.
• A revamping of Medicare's 3-day rule, which bundles payment for outpatient services provided within 3 days of inpatient admission into the inpatient payment.

Changes to the IPPS and MS-DRGs are available in the public domain through CMS' website as well as the Federal Register.

CPT Codes
Changes to CPT codes become effective with each calendar year on January 1. These codes are used to report procedures and services for physicians and hospital outpatients. Because CPT codes are owned and maintained by the American Medical Association (AMA), they are not available in the public domain. As such, finding a list of upcoming CPT code changes is often a closely guarded secret until the CPT book is published, generally around November or December each year.

The best way to get updates on upcoming CPT codes is to attend either the AHIMA's Annual Clinical Coding Meeting (September 25 and 26, 2010 in Orlando) for the national code update or the AMA's CPT and RBRVS Symposium (November 10-12, 2010 in Chicago). After the AMA's Symposium, it's common to see articles appearing in coding journals and publications discussing the upcoming coding changes.

HCPCS Codes
HCPCS codes are developed and maintained by CMS to report services, supplies, and procedures that are not found in CPT. They are utilized by physicians and hospital outpatient reporting. HCPCS codes are potentially updated quarterly, although an update isn't always required that frequently. HCPCS codebooks may be purchased on an annual basis with the calendar year and quarterly updates are found on CMS' website. HCPCS codes are in the public domain and general information about their use can also be found on CMS' website.

OPPS and APCs
The outpatient prospective payment system (OPPS) is the payment system utilized by Medicare to pay for hospital outpatient claims. This is updated on January 1 each year, along with the CPT and HCPCS codes. The proposed rule was published in the Federal Register on August 3 and CMS accepted public comment on that proposed rule through August 31. CMS will review the comments, make final determinations, and finalize the rule by November 1.

OPPS changes include recalibration of the relative weights for ambulatory payment classifications (APCs), the categories used to group similar procedures for payment.

Some highlights of the proposed rule include:

• Two areas that have undergone frequent changes or requested changes will remain static for 2011: drug and substance administration and hospital outpatient evaluation and management visit guidelines
• Establishment of a list of services that must be performed under physician supervision
• Removal of three orthopedic codes from the inpatient-only list, making them reimbursable as outpatients under Medicare
• A new method of paying for separately payable drugs
  

Information about OPPS and APCs can be found on CMS' website.

Physician Fee Schedule and RVUs
Physician payment, as outlined in the physician fee schedule, is updated annually on January 1 by Medicare. The proposed rule was published in the Federal Register on July 13 and the comment period ended on August 24. The physician fee schedule outlines the relative value units (RVUs) for each CPT code based on the amount of work the physician performs. Information on the Medicare physician fee schedule and RVUs is within the public domain and can be found on Medicare's website.

Too Much Information?
It sounds like an awful lot of information, but remember this - not every coding professional needs to learn the ins and outs of every coding and payment system. Because I work with hospital clients, I will be focusing on everything but the physician fee schedule. And those who work in physician offices will focus on ICD-9-CM diagnosis code changes, CPT/HCPCS code changes, and the physician fee schedule only. Even so, it's enough of an impact to call fourth quarter "coding season!"

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.

Get Your Paint Brush

I've been painting a lot lately. I recently had the intense urge to splash bold color on my bathroom walls. And I have to say, that while I love making drastic changes to a room and gazing admiringly at the finished product, the actual process of getting there drives me a bit nuts. While I was prepping and painting, it gave me a lot of time to think about... well, everything - including coding, mentoring, and blogging. And it struck me how much painting is like coding.

Maybe you don't paint the way I do, but as a typical perfectionist coder-type, I'm pretty picky about the end result. I always tell people that should this coding thing not work out for me, I'll go into interior design (LOL!). Finally, I've found a way to tie two of my passions together! At any rate, I hope you enjoy the analogy.

It's All in the Prep Work
First of all, I hate blue tape. Not because I have an aversion to the color blue, but it stands in the way of what I'm really looking forward to - the transformation that comes with brushing and rolling a new color onto the walls. And in an effort to paint the wall a dark purple with bright white trim while avoiding getting paint on the floor, it meant either a very steady hand or the use of blue tape.

While I was taping, my mind wandered to the people I've talked to who are trying to get into the coding field and how I often hear complaints about the education piece of coding. I liken taping off a room to getting a coding education. No one is going to recommend my painting skills if there is paint slopped all over the place. Likewise, no one is going to recommend me as a coder if I'm not educated.

Do You Have the Right Paint Supplies?
I wish I could say that my project took only one trip to the store to get the paint and the few supplies I needed (since I have the desire to paint something every year or two) -but it took three. The first trip resulted in a gallon of purple paint, ceiling paint, a tarp, blue tape (!), and a couple of other essentials that I couldn't remember if I had or not. The second trip garnered me a few more paint brushes for trim.

I thought I was set.

If only. At 6:00 pm on Sunday, I started going through paint cans of redecorating sessions past trying to remember which subtle shade of white was the right one for the trim. When I eventually found it, I opened the can and it was dried solid (when did I paint last anyway?!). I thought of using another white for trim, but while it wasn't dried out, it was in a sad state and ready to be retired. I thought about forgetting it and worrying about it next weekend. But I know me - it would probably never get done. So I headed back out for one last trip to get some trim paint.

Then I was set with another decision - which color of white should I get? If you've ever chosen white paint, you know there are about 5000 different shades of white. The old colors I had previously used were either a little two yellow or a little too green. So I selected a shade in the same color family as the purple and soon I was back home, painting the trim.

So how is this like coding? Well, if the prep work is the education, then your supplies are the educational institution you select. A higher quality institution means a higher quality you. I could have painted the trim with the yucky, rotten back up paint, but it wasn't the shade of white I really wanted and I knew the end result would not hold up to my standards. You can select an education based on cost, time, or promises the institution makes to you. But is it really a quality institution? There's a reason some educational institutions are more expensive. The only real answer to this is to get references from people in the industry. If you are working with a school, ask them to provide references from graduates. Make sure that the education you're seeking will set you up for the job you want, which means preparing you for the right certifications.

If you select the wrong educational institution only to find out later that it's an issue with hiring managers, be prepared to go back. Trust me. I was not happy that I had to go back to the paint store. But I am very happy with the end result. If you can't get anywhere with the education you received previously, find out what you need to do to get the education that will get you somewhere.

Don't Forget to Accessorize
Since I have fantasies of making a living transforming people's living spaces, for me no room is complete until it's been redesigned down to the last accessory. I've had this bathroom remodel planned for months, inspired by some personal stationary. I searched in stores and online for the perfect (and affordable) shower curtain, wall hangings, light fixture, and other room accessories. The end result was a complete cosmetic overhaul - the only thing I kept in the room besides the existing plumbing fixtures were the towel bars and soap dispenser. These final touches make all the difference. Let's face it - without them, this room is just a giant grape.

I always recommend that people accessorize their coding careers by picking up a specialty (or two). It's going to make the difference between you as a coder and you as a highly skilled coder. Specialties such as interventional radiology, cardiac catheterization, pain management, and radiation oncology are very difficult areas in coding. If you can code any of those specialties - and keep up with the frequent changing in coding rules and regulations - you will be highly marketable. But be careful. Unless you are willing to relocate to get a job, make sure you are seeking a specialty that is in demand in your geographic area.

When is the Painting Done?
I would like to tell you that the bathroom is done and it's beautiful and I will never change it. The truth is, I still need to replace the broken light fixture, hang the vanity mirror, and do a couple of touch ups. In another few years I will probably be sick of the color and want to change it again.

Likewise, once you complete your coding education, you won't be done. Coding requires continuous education to maintain your certification and keep up with medical technologies. And just when you get that most difficult area of coding down, Medicare will change the rules and you'll have to learn it all over again.

So keep up those painting skills and best of luck on your career remodel!