Coding from op reports improves with experience, because you train your eye to pick out what is relevant. Here are some general ideas, just off the top of my head.
- Check for what the question is, that is, do they want ICD and CPT codes or just one or the other
- Check for who you are asked to code for (anesthesiologist / both surgeons or one? / ED physician/ etc.
- Pull out key words for the procedure / condition
- Pay attention to site / age of patient / time frame / etc. because it might be important
- For exams with multiple choice answers (CPC, for example) scan the multiple choice answers to help you decide what you need to look for in the report.
- For exams with multiple choice answers, can you eliminate a couple of the answers because of wrong modifiers, or because code order violates Guidelines?
- Learn to skim over extraneous sentences such as the type of material used to sew up the incision and "all sponges were accounted for" and other phrases that don't affect the codes.
With the CPC exam, there are many questions that are not OP reports, so even if it not your forte, you have good chances of passing, so keep the faith! Of course, it is always good to practice so you feel more confident.
I'd be interested in reading what other ideas / advice others have to offer on this topic!
