Why coding matters? It IS medicine!

I have been asked by a lot of my peers as to why we need to learn coding. As if the 4-5 billion they (coders and billers) siphon off of your hard work isn't incentive enough, I say that communication and documentation via CPT criteria is just about the highest order language in medicine.

They then laugh at what I am saying. But think about it. How many times have you read someone else's note and had no clue WTF they were talking about or what was in their mind.

It turns out that if you just document your thoughts through the CPT system and according to auditing standards YOU WILL be communicating and no one will ever question your thoughts......

How does this type of documentation work? Well, you start by obtaining a history and making note of things such as

* Location
* Quality
* Severity
* Duration
* Timing
* Context
* Modifying Factors
* Associated Signs and Symptoms

Yes, of course you ask these things. But how many of you put this in your notes? You should? In fact if you do, you not only help other doctors out, but you also get paid more for what you do.....by including 4 of these with the problem, you can bill at E and M codes at the highest levels

Then let's obtain a family history......yes, you can do that. At least get the first 2 generations, Parents and Children or parents and grandparents. Why? Because you pick up diseases. But even if you don't pick them up, you at least document it for someone who may be able to see something in that tree.......

Past medical? Past Surgical? Ask your patients when they were diagnosed with their diseases and the medications that they had tried. Ask about ADRs. Even if you do all these things, unless you document it........

My point is, organize your thoughts on paper and in the way which includes recognition of the CPT auditing system. If you train your brain to think this way, you will be a higher order physician and your reimbursements will go up because of it. But most importantly, your patients will be healthier.