Guided Notes
Coding Practicum: Real-World Cases
Work through complete encounters the way you would on the job — office, ED, outpatient surgery, inpatient and risk adjustment — from documentation to clean claim.
How to work a case
Slide 1 / 6Use the same steps every time: 1. Identify the setting and payer (professional or facility? Medicare or commercial?). 2. Read the whole note; highlight diagnoses, procedures, time, laterality, devices. 3. Code diagnoses (guidelines, sequencing). 4. Code procedures/services (CPT/HCPCS or PCS), units and modifiers. 5. Link diagnoses to procedures (pointers) and check medical necessity. 6. Run edits (NCCI, MUE, LCD) and fix issues. 7. Note anything that needs a query.