Coding Practicum: Real-World Cases

Use the same steps every time: 1. Identify the setting and payer (professional or facility? Medicare or commercial?). 2. Read the whole note; highlight diagnoses, procedures, time, laterality, devices. 3. Code diagnoses (guidelines, sequencing). 4. Code procedures/services (CPT/HCPCS or PCS), units and modifiers. 5. Link diagnoses to procedures (pointers) and check medical necessity. 6. Run edits (NCCI, MUE, LCD) and fix issues. 7. Note anything that needs a query.