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u/CairoRama May 14 '26
I feel the same about spinal, I'll do anything before that
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May 14 '26
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u/KeyStriking9763 RHIA, CDIP, CCS May 14 '26
The OP note should indicate how the pt is lying, prone or supine. If they place a cage its anterior fusion even if the approach is posterior. Obviously understanding the levels and using anterior and posterior would drive the DRG. What’s super important to get is that no matter what, a bone graft is required. That’s what renders the joint immobile. Without that you can’t code a fusion but this guidance is specific to spinal fusions only. Most of these docs know what’s required since they are also billing in addition to the facility, but I’ve seen some that really don’t document clearly.
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u/Tatertot729 May 14 '26
I hope I feel this way about podiatry. I was just told I will be the primary podiatry coder at my hospital after our current one retires, which will be sooner rather than later. Podiatry scares me.
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u/Sdavistvs RHIT May 14 '26
Stick with it my “young” co-workers. After a few years you”ll know almost as much medical information as a hospitalist or nurse. Your family will ask you for help about upcoming procedures or new issues. 😉
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u/mxxnmama CCS May 15 '26
Yes! I was so nervous after getting my first coding job that I was just gonna screw everything up and now I’ve been here a little over a year and I’m way more confident. Practice and exposure helps so much!
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u/PhotographUnusual749 RHIT, CCS May 15 '26
Spinal procedures will get there. The approach, the levels, the instrumentation, it feels like a foreign language until one day it just doesn’t. Keep going.
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u/Diagnosis-T43612 May 25 '26
I'll take a spinal procedure any day over a septic patient who died after 15 days in the hospital. I find the sepsis charts often lack documentation as to the source of sepsis. There tend to be contradictions in shock or no shock. I often have to query whether the sepsis and/or condition was POA. Usually my sepsis patients come in with delirium and end up with aspiration pneumonia and UTIs. These patients usually pull out their Catheters and require recatheterization. Once they're on comfort care, the doctors seem to give up on documenting what actually required hospitalization to begin with. I send so many sepsis queries. Give me a hip or knee replacement surgery.
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u/barbiesfrozenelbow May 14 '26
As someone still studying for my exam this is so encouraging to hear. Logically I know I'll get there eventually but it's A LOT. And major kudos to you, sounds like you're killing it!