Chart Talk ~ Anesthesia Coding Conversations

Anesthesia Coding • Auditing • Compliance • Education

A new week doesn’t always require learning something new. Sometimes, it requires trusting what you already know. As coders and auditors, we spend a lot of time verifying. We check the documentation, review the guidelines, research the payer policy, look at CPT®, check NCCI edits, and we ask questions and we should. There comes a point when the research is complete and a decision has to be made. That can be the harder part. You may have the skill to make the decision but still hesitate because you aren’t completely confident in your judgment.

You may find yourself thinking, what if I missed something, should I ask someone else first, what if they disagree with me, and maybe I should research it one more time. There is nothing wrong with verifying your work, but verification and hesitation are not the same thing. Part of becoming stronger in anesthesia coding and auditing is learning when you have gathered enough information to make a well-supported decision.

This week, take your resources with you—but take your judgment, too.

When you encounter a difficult case, Read the record, identify the actual coding or compliance question, go to the authoritative source, apply the guidance to the documentation in front of you, document your rationale when appropriate and then Make the decision.

You don’t have to know everything to be a strong coder. You do need to know how to research what you don’t know, recognize reliable guidance, apply it appropriately, and stand behind a decision that is supported by the documentation and authoritative resources. Confidence isn’t pretending you’re always right. It’s being able to say “Based on the documentation and the guidance available to me, this is why I reached this conclusion” and being willing to reconsider when new information shows you something different. That is how judgment develops. That is how experience becomes expertise.

So, as you begin this week, ask yourself What am I taking into this week? Maybe it’s confidence, curiosity, patience, the willingness to ask a question, or maybe this is the week you stop automatically assuming someone else knows better and start giving your own knowledge and experience a seat at the table.

This Week, I’m Taking…Trust what you know, Research what you don’t, and Know the difference.

What are you taking into this week?

Share yours in the comments. Someone else may need the same reminder today.

Chart Talk – Anesthesia Coding Conversations
Lead. Educate. Comply. Excel.


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