Free coding guide

4 Coding Hacks To Improve Productivity- A Guide For Medical Coders

Announcing a free guide for medical coders: 4 Coding Hacks to Improve Productivity.

Many of us have struggled with meeting production requirements, so I’ve put together this guide. There are 15 pages and it talks about what I’ve used to improve my own coding production requirements. In general, I think it just takes time, but there are things you can do to help in the beginning. This is a free download. Get it here. 


Go here to download



coding challenge

Coding Challenge 7

Please code the CPT and ICD-10-CM code for this report. This report is HIPAA compliant and does not contain PHI.


Exam- Right hip including pelvis 2-3 views

Date- June 4, 2018


Exam-Hip x-ray right including pelvis 2-3 views

Clinical History- Right hip pain

Comparison- hip x ray 2/4/17

Technique- 2 views of the right hip and 1 ap view of the pelvis was performed

Findings: Pelvis ring intact. The sacroiliac joints are symmetric. No right hip fracture or dislocation. Punctate ossific density adjacent to the right hip. Left hip unremarkable.

Soft tissue- normal


No right hip fracture or dislocation. Punctate ossific density adjacent to the right hip most likely related to degenerative changes.


Thank you for referring your patient.

Go here for the answers

coding challenge

Coding Challenge 6

Please read the report below and code the CPT and the ICD-10-CM Code. Please keep in mind that these reports are designed to be as realistic as possible, but everything is HIPAA compliant so the information is not real.

*For the tomo, please use the HCPCS code.


Procedure- Bilateral Diagnostic Mammogram with Tomo

History- Bilateral breast pain for 2 weeks

Technique- Full field mammography was performed. Bilateral breast tomosynthesis was preformed in the MLO and CC projections. CAD was used as an aid for interpreting this exam.

Comparison: Prior mammo from April 2017

Density- There are scattered fibroglandular densities

Findings: There is no suspicious mass, microcalcifications,  or unexplained distortions.

Impression: No dominant mass or secondary signs of malignancy within either breast. Annual screenings recommended. BIRADS ASSESSMENT- (2) Benign findings.

Signed Dr. J.

Go Here To Check Your Answers

Youtube tutorial

X-Ray Coding–A Walk-Through With Examples

If you’re new to radiology coding, or just want to learn more about it, this is a good video for you to watch. It is a quick 5 minute tutorial where I go over the format of an x ray report and the elements that should be included. There is also a practice report in it for you to code the cpt and icd-10 code.

Thank you for watching this tutorial!





coding challenge

Coding Challenge 5

Please code the ICD-10-CM and CPT code for this report. To check your answers, click the link at the bottom of the report.

ABC Hospital

Patient Name- Jon Doe

Date- 1/1/18

Referring Dr- Dr Smith

Exam- US Renal


Procedure- US Renal

History- Routine check of renal cysts

Technique-2D images

Findings- Complete evaluation of the right kidney. Right kidney is normal in size with no hydronephrosis. No calculus. Simple cyst measuring 1.4 x 2.1 x 3.6 located mid portion. Simple cyst #2 measuring 1.7x 1.9 x 1.6 located upper pole.

RT kidney retroperitoneal measurements- length 9.71 AP 5.04 cm. width 5.52 cm

Complete evaluation of the left kidney. The kidney is normal in size with no hydronephrosis. Complex cyst measuring 2.2x 1.2x 1.5 located mid portion. Visualized portion of the IVC are normal. Proximal and abdominal aorta obscured by bowel gas.

LT kidney retroperitoneal measurements- length 11.50 cm AP width 6.25 cam

The bladder is normal.

Prostate is normal.

Impression- No hydronephrosis. Bilateral renal cysts.

Signed by Dr Michaels 4:00 pm 1/1/18

Go here to check your answers!






Medical Coding Job Search Tip: Make A Portfolio

background-blur-bright-684314So if you’re out there right now looking for a medical coding job, I’m sure you realize how tough it is. Many places require experience to get hired and even then , sometimes experienced coders have a tough time too. There are some small things you can do to help you have more success with your job search, but the one I’m talking about today is to make a portfolio.

I think people hear the word “portfolio” and panic because they don’t know what it is, and it sounds like more work. “Portfolio” to me, is just a nice word for “binder.” This doesn’t have to be some long involved kind of project.  You probably already have a lot of stuff you can put in the portfolio and you don’t even realize it. The good thing is, if you bring a portfolio on an interview, it can only be a positive thing and make you look better than other people applying for the same jobs you are.

Also, the portfolio has another purpose, not just for use on job interviews. It’s a way to keep track of all your CEU certificates. If you’re a member of AAPC, you have to submit your CEU’s to keep your certification active. If you keep all certificates in a portfolio, it’s easy to enter in all of the certificate numbers, and you’ll know you’re not forgetting to add anything. Another benefit is, if AAPC decides to audit your CEU’s (which they did to me 2 years ago) it is easy to copy your certificates and send them in. So in other words, it’s a nice way to stay organized.

Ok, so here is a pic of my actual portfolio. I wasn’t kidding when I said it meant “binder.”

My portfolio

You can add a cover or make it fancier if you want, but I never did.

Now, there’s different things you can put into the portfolio itself. I have copies of my CEU certificates like I mentioned before, and also copies of articles I’ve been quoted in, my resume, copies of my coding certification and a copy of my college degree. If you really want to get creative with it, maybe adding pictures of your home office would be nice too. My desk is too much of a mess compared to others so that is why it is not featured in here. But it is not a mess to me. I know where everything is.


Here are more pics of my portfolio:

You can get as creative as you want with it. Mine is pretty basic but it helps just to keep things organized. It doesn’t really matter what you decide to put in here as long as it’s professional and highlights your skills. I would just suggest putting all documents in a plastic sleeve/cover though.

So, next time you go on an interview–bring your portfolio with you. It will help you stand out compared to other applicants and who knows–may help you land a coding job.

PS-Here are links to some binders you can use to make your portfolio:

Good luck with your job search!





Coding Tip- Always Follow Client Guidelines

Ok, well this might be a no-brainer, but always follow client guidelines. I know you already have to think about all of the ‘real’ coding guidelines, but that does not mean that clients don’t have their own that you must follow too. This makes your job as a coder a little more difficult because there’s more to remember, but eventually you’ll be able to code and your clients guidelines will become second-nature.

So, what am I talking about exactly? Most clients that I’ve coded for have their own set of rules. I’m not saying that these contradict real coding guidelines, but basically clients have rules too. For example, there may be guidelines on whether or not to use the LT/RT modifiers or modifier 50. There may be client guidelines on what to do if the report has documentation issues, or if some info is completely missing. You should know if your client wants outside reads coded because some do, some don’t. A very important one you should know is whether or not your client needs you to add modifier 26 or not. You will get this info before you start actually working for the client. They should send you a pdf or another document specifying their guidelines.

There could be many different client guidelines and the ones I mentioned are just a few that are possible. Always remember to check your client coding guidelines if you come across a situation that you’re unfamiliar with and you will hopefully find the answers to your questions. If not, then the best thing to do would be to contact your lead coder/coding manager for clarification.




Tabs For The ICD-10-CM Book

I was thinking about “coding hacks” that make my life easier. For my job as well as many others out there, coding speed is an important factor. We have to code a certain amount of charts in a certain amount of time. This can be tough to do especially if you rely solely on your books. But it’s a catch 22 because I WANT to rely on my books.

I’ve done way too many audits where the codes were chosen buy an engine. These codes were incorrect for a variety of reasons–laterality, order of codes, or just completely wrong for no apparent reason. All of this has led me to use my coding books when I do my coding.

So I made these tabs and it is a lifesaver. I can code faster because I can find the codes quicker. Also, what I like best about the tabs is that they are double-sided so I can see all parts of the book without flipping back to the beginning. This is good for coders already working, but I think this might be especially beneficial to people taking their coding exams.

So I decided to make more of these and make them available to other coders who can benefit.

There are 60 pre-printed, multi-colored, double-sided tabs included,

for $14.99.

Please see the pics below!

To purchase, please scroll to the bottom of the page.

Tabs For The ICD-10-CM Book

This product contains 60 pre-printed, double-sided tabs for the ICD-10-CM book.


This item is in production and will ship on August 28, 2018.


Is Diagnostic Radiology Coding Really Easy?

Ok, I’ll just come out and say it–many times in coding discussions, I’ve heard people say that diagnostic radiology coding is easy. That it’s a good place for new coders to start. I’m not really sure how I feel about that. Not that it’s not a good place for new coders to start (it is) but that it’s so easy– anyone can do it. I’ll admit it’s much easier that interventional radiology coding, and some of the other specialties out there…but diagnostic radiology is it’s own specialty. It has it’s own set of rules and if you’re not a radiology coder–you won’t be familiar with it. I mean, yes, you could learn it–that’s why I started this website–to help new coders learn–but does it sound weird if I feel bad that people think it’s very easy to code?

For starters, here are some of the little idiosyncrasies that a diagnostic radiology coder knows off the top of her/his head:

*Understands modifier 26 and TC

*When to use modifiers 59/76/77/52/53

*How many organs are in a complete abdominal ultrasound vs limited

*The difference between all of the different types of OB ultrasounds

*The documentation requirements for spectral Doppler (now if we can teach radiologists how to document this right, we’ll really be in good shape).

*The different contrast codes for mri’s and ct scans

*Understand the difference between an mri, mra, ct, cta and pet scan

*Difference between a screening and diagnostic mammogram

*The physician ordering rule

*All the different cpt codes for x-rays

*The different types of x-ray views

*Knows the codes in the 7000 series without looking in the cpt book

*All of the different PQRS codes that may be required and the documentation requirements for each

*Understands that “initial encounter” for fractures/injuries does not mean first encounter.

*The whole ICD-10-CM book because codes are used from every section!


Another part of diagnostic radiology coding that is specific to it, is the speed at which you’re expected to code. On average, a coder should do 60 reports an hour at 97% accuracy. Many coders can do more, but this is the expected rate. There are short cuts–like different encoders that can help coders keep up the pace, but ideally I think a radiology should be able to code 60 an hour without much help. It’s a specialty where there always is a lot to code, so you have to hit the ground running.

The only way to work your way up to that speed is by practicing! There are no short cuts. I once had a teacher that said “the more you practice, the better you get.” That still holds true years and years later (Thank you Mrs. Jaffe). Here is a free diagnostic radiology coding test if you’re looking for more practice.

Anyway, with all that being said–I love diagnostic radiology coding and I know I’m biased, but I just think it’s the best and I can’t help but feel bad if people put the specialty down without fully understanding it.

All of the above topics (and more) are things I plan to talk/write about at some point, so if you’re interested in learning–keep following this blog and facebook page 🙂