Yes there alot of words and #'s in the ICD(Diagnosis) and CPT (procedure) books. But a superbill like I mentioned above is cake to make on a computer. Just start writing your common cases and look them up. There's only a couple options for a gallblatter. Acute or calculus, then scopic or open, then the RVG . It doesn't matter if there's a bile duct exploration, LOA, foley insertion etc. for us.
Here's one: Hematuria > 599.71 , Cysto > 52000 , RVG> 00910 . The rest is on the face sheet and the record- which you should have a copy of to take with you. PS 3, 4 ? add it....popped in an IJ ? add it , A-line add it, Epid for post op pain? Femoral N. block? You'll only look these up ONCE. Then you'll write them down. Like I said, mine is 6 pages, I could shrink it to 3 and cover 95% of what I do. I still have my original handwritten copies in the briefcase that follows me to every OR. There's gotta be some smartphone app for coding. I am old school and enjoy my dumbfone so no apps. If you do it in the OR it's painless, if you let em pile up like I did recently, I sat for an hour and knocked out 3 or 4 weeks worth. I hold my charges for 4 weeks so the facility and surgeon can deal with deductibles.
