The various specialties available for those to be involved in are many and can vary greatly by the body system of main focus and that physician’s role in the care provided. Anesthesiologists, radiologist, surgeons, and primary care physicians all play a vital role in our lives at one time or another, and with that involvement comes the need for coders to specialize and be more familiar with the ins and outs of the needs of the patient and medical staff.
The specialty of anesthesia is broad and involved in so many aspects of care, in every body system. Anesthesia can come in the form of a local, regional, or general type giving increasing levels of sedation and pain management. An example of local anesthesia is when a numbing agent is injected “directly into the area of the body, which will block pain in minor procedures” (Smith, 284). This can be used while suturing the skin or during debridement of an injury. An example of regional anesthesia is more like a nerve block applied to a larger area of the body, such as the extremities. Epidurals during childbirth are also another example of a regional anesthetic. Finally, general anesthesia is when full sedation is administered to the patient either “intravenously or by inhalation” (Smith, 284). For coding purposes, there are many aspects to locating the correct code, such as timing of the procedure and how involved the anesthesia was during the procedure. Also, modifiers indicating the general health of the patient undergoing anesthesia are important to indicate how complicated the anesthesia may have been. Additional codes may be reported when, “anesthesia services are provided under difficult circumstances because of the patient’s condition, operative conditions, or unusual risk factors” (Smith, 286). These additional codes are “reported along with the code describing the basic anesthesia service” and include advanced age of the patient, the use of total body hypothermia, the use of controlled hypotension, or even emergency conditions (Smith, 286). In general, the specialty of anesthesia is incredibly necessary in every branch of medicine and with that comes the complicated nature of coding for this specialty.
The specialty of radiology is similar to anesthesia in that it covers and is a part of many other specialties and is involved in every body system. Radiology includes x-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and ultrasounds, among other procedures to not only diagnose but they are also used during the course of treatment. Radiation oncology is a main component in the treatment of neoplastic tumors. Ultrasounds, for example, are used to guide the physician during the performance of an amniocentesis. In regard to coding, modifiers play a huge role in accurate code assignment. Some common modifiers used include 51, 52, and 53, while a modifier more specific to the radiology specialty is modifier 26, Professional Component. This modifier is used when “a radiological procedure includes both a physician/qualified healthcare professional component and a technical component, modifier 26 may be reported to identify the physician/qualified healthcare professional component” (Smith, 192). The professional component “includes supervising the procedure, reading and interpreting the results, and documenting the interpretation in a report” (Smith, 192). This modifier comes into use as this professional component can be fulfilled by either the ordering physician or by a radiologist on staff. Paying close attention to the details of the radiology procedure performed is critical as there are multiple types of tools and methods used in the completion of these procedures.
The surgical specialty is subdivided into body systems with surgeons choosing to focus their studies and expertise into one body system. With the exception of general and pediatric surgeons, general surgeons focus primarily on the abdominal area while pediatric surgeons focus on children, infants, fetuses, and adolescents up to young adults. With regard to coding for surgery, the surgeon and coders must work together to ensure proper documentation of the surgery and any details that may allow for more specific and accurate coding. While coding surgical procedures, it is important to note if the procedures performed are combined into a surgical package. A surgical package “refers to a combination of individual services provided during one surgical operation” (Smith, 60) and is “treated as one single service for purposes of reimbursement” (Smith, 60). Ensuring that proper documentation comes from the surgeon allows for quicker and more accurate reimbursement.
My last area of focus is probably the one most often encountered by patients, evaluation and management services. This specialty is focused on “services provided by physicians during hospital and office visits, skilled nursing facility visits, and consultations” (Smith, 215). These can include visits to your primary care physician for a routine yearly physical or during times of illness. Areas of interest to coders include the detail of the documentation from the physician or qualified health care provider, such as, review of symptoms, past, family, and social history, and in the event of current illness, the chief complaint and history of the present illness. “Generally, it is preferable that physicians select evaluation and management codes” (Smith, 215), this allows for coders to “validate and verify the physicians’ code selections” (Smith, 215) based on guidelines set forth by the Centers for Medicare and Medicaid Services and the American Medical Association.
In conclusion, I feel that more often than not, physicians and coders will have a specialty that they are more interested in than others, so taking the time to learn about the demands and workings of those specialties is invaluable. To find an area that truly interests someone would make a huge difference in their outlook towards their career and generate genuine curiosity and attention to the ever-changing field of medicine and medical coding.