Q: What does Practicode case look like and how do you abstract from it?
A: I’m not taking you to Practicode, what we do on a Thursday night student webinar support calls is that one portion of that we do Practicode cases because we have Practicode students. This is a particular case that we pulled out, that I went ahead and put in this document so that we could practice abstracting and pulling the information from the document that was pertinent so that they could see the divisions of a report. Usually when you get a report – and this is all redacted, this is a real case but it’s not the real person.
You have this patient, it tells you the date of service and then the doctor, the insurance. The insurance is important because if they’re Medicare patient you might have HCPCS code or something that needs to be used. Then, you’re going to have HPI (History of Present Illness) that is given. This is usually what the patient is telling the doctor, like, “Yeah, look, see I have GERD and I have some thoracic pain.”
Then, they’re going to start breaking down the information after that as problems, allergies (no allergies reviewed). Then you’re going to see a list of medications the patient is on, which would corroborate any type of illness that the patient had. Then, vaccines and stuff. Then you’re going to start getting into the history; you’ve got a Social History, a Past Medical History, and a Family History that’s reviewed. All of this information is pertinent when you go to pick your CPT code.
What does a Practicode Case Look Like – Video
Surgical History – there might be hidden codes in here, if the person maybe had a below-the-knee amputation in 2010, then that would be an additional code that you might be able to add to that if something is going on with that stump. Or they had PVD. Then, he’s looking into some of the medications. The Physical Examination – now everything is changing, this is what the doctor is actually looking, touching, feeling, seeing with the patient. This is divided up into different body systems.
Then, you get down here and you get the Assessment and the Plan. This is the diagnosis is the assessment and what does he plan to do about it? Well, this person, he’s getting medication for that GERD. These are all medications that treat GERD. He’s got hypothyroidism, and then what is he doing for that? What medications is he given?
In the end, what labs and stuff are being reviewed? If there’re labs that he’s asked for, that changes the CPT code and makes that bump up to a different level , usually. Then, when you look at the signature and there’re rules about the signatures. Ultimately, in this particular case came to be a 99214 and the reason why there’s a 1, 2, 3, 4 behind it is that we have four diagnoses here and each one of those diagnosis goes with that CPT code, so therefore it’s coded there.
That’s how you abstract the information, it’s not in-depth, but on the Thursday night calls we do break these down and pull them apart. We discuss them and even get into, if somebody does not understand what GERD is, then we go look it up and show them examples of GERD. It’s a lot of fun. If you are a PBC student, a Blitz student, or a Practicode student, you’re more than welcome to come in and be a part of those Thursday night calls at 6:30 Central every Thursday except the second to the last Thursday of the month, because we’re here.
Laureen: We’re doing this. And also, regarding the Practicode, you can go to our YouTube channel and type in Practicode, and there’s a bunch of different clips that we’ve done over the past several months where we’ve highlighted some Practicode cases. But we can do another one where it’s more of a demo. It sounds like that’s what the person is interested in, seeing what it’s like before they purchase.
Alicia: Right. We have a video where we had some people go in and sat in on that video that we did with the Practicode people and they really appreciated that. Keep in mind that Practicode is not necessarily a good thing to get, to use while you’re learning to code. These are real-world cases not cases written and designed to help you learn the guideline and help you with the testing and confirming those. These are cases to really hone your skills, so keep that in mind if you want to work with Practicode. Great, great program.
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