17. The Medical Record: What Do We Code From?

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  • เผยแพร่เมื่อ 22 ม.ค. 2025

ความคิดเห็น • 73

  • @elizabethgonzalez1419
    @elizabethgonzalez1419 ปีที่แล้ว

    I’m new as medical records director thank uuu for u info !

  • @tammyhughes1272
    @tammyhughes1272 3 ปีที่แล้ว

    Do you need to be a cpc coder to abstract icd 10 and cpt codes from a medical record

  • @melissakinney739
    @melissakinney739 5 ปีที่แล้ว +2

    I think code master coach is the best source while trying to take coding online, she is very thorough and explains coding where I truly understand. Thank you very much

  • @suzannehalesuzzz4895
    @suzannehalesuzzz4895 5 ปีที่แล้ว

    as an out pt coder we are not allowed to determine or use a dx from a lab report.

    • @codemastercoach6636
      @codemastercoach6636  5 ปีที่แล้ว

      I understand Suzanne Hale SUZZZ. I was recently told the same thing. However, I still view the lab report to help me understand my physicians diagnoses and if I notice my physician missed a diagnoses, I use these lab reports to help me justify my query.

  • @Toyi-5000
    @Toyi-5000 4 ปีที่แล้ว

    😍 thank you

  • @shersal6556
    @shersal6556 6 ปีที่แล้ว +5

    Hello Coach! I want to say a Big Thank you!.. I am making a career change to medical coding and have started studying for the CPC. I'm so lucky to have stumbled upon your videos and am totally hooked! You are such an amazing teacher and with every video that I watch, I gain more confidence and drive to do this!. Thank You so much! and God bless you!

  • @sandysandip4428
    @sandysandip4428 4 ปีที่แล้ว

    Awesome

  • @blkqueenk2717
    @blkqueenk2717 7 ปีที่แล้ว +9

    Hello! I’m having trouble dissecting the medical record. Do we code past history? Examinations? I don’t know where to start when I’m given a medical record. Please help!

  • @chrisellely-portlandorreal9004
    @chrisellely-portlandorreal9004 5 ปีที่แล้ว

    You are such a GOD-SEND

  • @sueannsquyres1835
    @sueannsquyres1835 6 ปีที่แล้ว +1

    Coach, I am so relieved you've shared your WEALTH of knowledge with everyone. I've found your channel very helpful and encouraging. I look forward to watching in the evening time. It has actually replaced a lot of my Netflix watching. I long to have ALL your CODING KNOWLEDGE. Thanks again.

  • @brendawhiteside4779
    @brendawhiteside4779 6 ปีที่แล้ว

    what's the difference between icd 10 and icd 10 cm

  • @EDZE1105
    @EDZE1105 8 ปีที่แล้ว

    Have question what happen if we put wrong code in system

    • @codemastercoach6636
      @codemastercoach6636  8 ปีที่แล้ว +4

      Then you get reimbursed based on the wrong code and then if/when you get audited, they will take money back from you.

  • @TysVideoDiaries
    @TysVideoDiaries 7 ปีที่แล้ว +9

    Love your channel! Love how you are breaking this down so that anyone can understand and follow. Just subscribed last week. Been in billing for over 10 years and recently registered for the coding courses offered by AHIMA.

  • @valerielb77
    @valerielb77 8 ปีที่แล้ว +7

    You are just what the doctor orderd, thank you so much for the insight. God bless

    • @codemastercoach6636
      @codemastercoach6636  8 ปีที่แล้ว

      Thank you. You are welcome.

    • @worthy7834
      @worthy7834 7 ปีที่แล้ว

      CodeMaster Coach ..Hey, luv ur videos, was wondering if u had or will make videos regarding nursing home/ Assisted living facility coding?

    • @ibtissamcasablanca4060
      @ibtissamcasablanca4060 6 ปีที่แล้ว

      Haw can we get job

  • @ziona2000
    @ziona2000 8 ปีที่แล้ว

    Have you found that physicians are appreciative of querys? Thx

    • @codemastercoach6636
      @codemastercoach6636  8 ปีที่แล้ว +1

      No Katrina Fowler. I really have to beg them to complete them.

  • @EDZE1105
    @EDZE1105 8 ปีที่แล้ว

    What's the way to fix it

    • @codemastercoach6636
      @codemastercoach6636  8 ปีที่แล้ว

      If your referring to submitting the wrong code and fixing it, you can submit a corrected claim form.

  • @sandrasulinski7660
    @sandrasulinski7660 6 ปีที่แล้ว +1

    I have a question.. Where all these coding books are expensive and I know that they come out with them every year, in your opinion, is it necessary to purchase these every year? Also, I have just enrolled in UMA for my Associates degree in Medical Billing and Coding which I will be graduating in 2020. Should I order the 2019 version of all these books or wait for the 2020? I know It will help me in having these books while I am enrolled in my courses so I am conflicted in what I should do when it comes to purchasing these expensive books that come out every year.

    • @marissa8855
      @marissa8855 5 ปีที่แล้ว

      I am at UMA and they send our books to us if you are an online student, I got the 2019 CPT manual. I graduate 2019

  • @paulmadore7795
    @paulmadore7795 4 ปีที่แล้ว

    Thanks for another great video! I am going to take some time to review my notes from videos 1 - 17 before leaping into 18's "Basic Steps".

  • @lechristnaprice4833
    @lechristnaprice4833 6 ปีที่แล้ว +1

    You are such a good teacher thank you ❤️

  • @TheBluebird101
    @TheBluebird101 8 ปีที่แล้ว +1

    I have a question I am thinking about going to school for this field would I be able to take the state exam if the school is not accredited and will it be hard for me to get a job cause the school is not accredited

    • @codemastercoach6636
      @codemastercoach6636  8 ปีที่แล้ว +2

      Hi Valerie, AHIMA requires their schools to be accredited for the RHIT and approved for the CCA. AAPC does not require accreditation for the CPC. Coding jobs do require certification so please take this into consideration .

    • @natalee1036
      @natalee1036 8 ปีที่แล้ว

      i would start with a CCA from AHIMA... it is a very hard test amd a nice guy from AHIMA guided me in the right direction so give them a call ... classes through AHIMA and AAPC are the way to go...in my opinion

    • @TheBluebird101
      @TheBluebird101 8 ปีที่แล้ว

      CodeMaster Coach I live near Nashville Tn and the school here for billing and codeing is 15 to 20 thousands is there a cheaper way

    • @natalee1036
      @natalee1036 8 ปีที่แล้ว +1

      AAPC AND AHIMA are about 6 grand that is coding and billing I did both. Online tho

    • @TheBluebird101
      @TheBluebird101 8 ปีที่แล้ว

      Nat Alee what online program you go thru

  • @sheetalkumar9714
    @sheetalkumar9714 7 ปีที่แล้ว

    dear coach i have 2017 year code books but my exam is on january 2018. can i use 2017 year code books for exam

    • @khalidabatarseh7534
      @khalidabatarseh7534 6 ปีที่แล้ว

      Which book did you used and how was the exam I am prepare for the exam

  • @Kimberly4UGA
    @Kimberly4UGA 7 ปีที่แล้ว +2

    You are so clear and concise... I love it!!

  • @lovelace89
    @lovelace89 6 ปีที่แล้ว +8

    Coach,
    Is there a place for me to access coding software or mock records to practice? I had access to the encoder while in school and I am wanting to brush up on my coding.

  • @marloann4
    @marloann4 5 ปีที่แล้ว +1

    Yay I’m moving right along

  • @Besty190e
    @Besty190e 6 ปีที่แล้ว

    I worked for my father as a clerk in his doctors office I have experience in medical records will this help me when I go to school for coding?

  • @Blue-fr1os
    @Blue-fr1os 7 ปีที่แล้ว

    what do the medical records look like that you are coding from? Do they come to you in digital form or are you actually shuffling through some paper reports from the doctors and nurses, hospitals, etc.?

  • @tarrikliewer9674
    @tarrikliewer9674 7 ปีที่แล้ว +1

    Thank you so much for the many videos you have up; they are so helpful and your delivery is excellent!

  • @Queen5Star
    @Queen5Star 6 ปีที่แล้ว

    Thank you sooooo much!!

  • @HeavyK.
    @HeavyK. 6 ปีที่แล้ว +1

    This Girl Is Awesome! I wish you was my teacher.

  • @brendawhiteside4779
    @brendawhiteside4779 6 ปีที่แล้ว

    Hello, since I just became one of your followers should I start with your 2018 study guides. I would like to do a exercise everyday.

    • @codemastercoach6636
      @codemastercoach6636  6 ปีที่แล้ว +1

      Actually, you can do everyone of the videos on my channel. They all still apply to coding.

  • @dawnmarie291
    @dawnmarie291 6 ปีที่แล้ว

    Hi Coach! I cannot thank you enough! These videos are a God send! I appreciate you more than I could ever express!!! I have 3 questions for you, please? If I recall correctly, in another video you mentioned that we had to use the dx that the provider listed in the document, rather than going off of the lab report, (and/or to query the provider). Question 1): If I am coding a chart a week after the visit, and the lab result for a documented diagnosis of a skin tag, turns out to be a wart, do I a) change the code to match the lab, b) I code what the provider documented or c) only change the code if the provider clarifies in a query. Part 2 of this question.... If the provider answers in a written query, do they also need to go in and add an addendum to the chart so that the dx is supported by documentation or is the lab result sufficient?
    2) In this video, you mention an x-ray result that would provider more specific area of where a fracture occurred. Is it ok to use that definitive radiology report to change the code or do I need to query the ordering provider if it is different than in his E/M note?
    I guess what I am not sure of is at what point I use the lab and/or rad report, vs. the chart note and is additional documentation required. Please advise
    Thank you, again!!!!

    • @codemastercoach6636
      @codemastercoach6636  6 ปีที่แล้ว

      Excellent questions Dawn Marie Holidays. If the diagnoses is totally different after a week and the physician did not have the lab results at the time of discharge, then yes, query your physician. When the provider answers the query, that query becomes your documentation for the chart and for coding purposes. With the specificity of the x-ray, most times the physician will state ankle x-ray but does not state which bones were involved. So as long as the x-rays specify which bones, you are ok to specify in your coding. It will not require additional physician diagnosing because the provider already specified fracture. I promise with practice, this will get easier.

    • @dawnmarie291
      @dawnmarie291 6 ปีที่แล้ว

      THANK YOU SO VERY, VERY MUCH!!!! This is very helpful information to have! Just one tiny piece of clarification,..... so in using an electronic medical record, such as maybe, EPIC, and I send an email inquiry, (or inbasket - which is part of EPIC), would I then scan their response into the system so it could be attached with any medical records in the case of an audit?

  • @michelerevels3128
    @michelerevels3128 7 ปีที่แล้ว

    Just found your channel and i love it. Just subscribed. I love how you break down all aspects of coding and all it encompasses. Thank you

  • @leubic
    @leubic 5 ปีที่แล้ว

    💯

  • @arundabholkar4922
    @arundabholkar4922 6 ปีที่แล้ว +1

    Good learning experience from your videos on coding. Is it possible to learn coding from your videos alone and give the national exam, and then work as free-lance coder?

  • @jack2427
    @jack2427 6 ปีที่แล้ว

    thanks coach

  • @jenniferpena8043
    @jenniferpena8043 7 ปีที่แล้ว

    Thank you and I love you, Code Master Coach!

  • @sandysandip4428
    @sandysandip4428 4 ปีที่แล้ว

    1Billions time s Thank u madum

  • @helenabera6255
    @helenabera6255 7 ปีที่แล้ว

    love this. Thank you so much

  • @brendawhiteside4779
    @brendawhiteside4779 6 ปีที่แล้ว

    I go to sleep every night listening to your studies in my head while you drill me on u-tube. You make everything so simple and to the point. You remind me of Moses in the bible a great teacher and leader. I love you code master coach. Keep up the good work because God has truly anointed you to teach. I want you to give me your all!

  • @305heat_
    @305heat_ 5 ปีที่แล้ว

    How’d i miss this? This is the Meat and Potatoes of the coding field

  • @BackCatGD
    @BackCatGD 7 ปีที่แล้ว

    Very good, excellent video clear and concise..Have you any email to contact you? Greeting from Venezuela