Documentation and coding for capturing patient conditions, which drives severity and reimbursement as well. documentation specialist and the medical staff to encourage physician cooperation for thorough and specific documentation
Without such documentation accurate coding cannot be achieved. be used when the documentation in a medical record does not specify the type of COPD being treated. 2. Acute exacerbation of chronic obstructive bronchitis and asthma
1 E/M Coding andE/M Coding and Medical Documentation Proprietary and Confidential September 13-15, 2011 Presented By First Coast Service Options, Inc.
Overview: Medical Records Documentation and the Coding Process Each time a patient seeks health care from a provider, the encounter is documented in the medical record and a diagnosis and/or a procedure code records the activity.
Medical documentation, with entry-level proficiency. Learners apply CPT instructional notations, conventions, Medical Coding Specialist or 305302 Medical Coding Specialist program requirements met 10530185 Healthcare Reimbursement
Ana-based coding instructor and medical office auditor. “A staffer can look at the exam and count the necessary elements, but the physician has a true handle on the medical component. and rely on the coding and documentation professionals.
CPT Coding One of the more common documentation errors that results in the failure to support procedure code assignment is reporting the measurements of the lesion and margins. Z-plasty, adjacent tissue transfer, etc), in the medical record documentation.
»Appropriate methods for resolving coding or documentation disputes with physicians documentation in the medical record: 1. A history and physical 2. Written progress notes 3. Physician orders for admission to observation and for treatment 4.
Summary: Review clinical documentation and diagnostic results as appropriate to extract manager—Clinical Coding, or manager—Medical Record Services, accurately code inpatient conditions and procedures as documented in the ICD-9-CM Official Guidelines for Coding and
If a key medical detail is missing, then coding can be inaccurate. Inac-curate coding may lead to inappro-priate compensation for utilized re- ing documentation and coding are (1) the attending physician on the case is the ultimate determining au-
A/B MACs by Jurisdiction CONTRACTOR STATES J1 Palmetto GBA California, Hawaii, Nevada & Guam J2** National Heritage Insurance Co. (NHIC) Alaska, Idaho, Oregon & Washington
•The importance of accurate documentation OBJECTIVE Medical coding specialists translate a physician’s documentation into ICD-9-CM and CPT codes. Codes submitted for reimbursement become part of the statistics used for quality assurance, research, grants, studies, vital statistics (births,
Medical Coding Specialist AWARD: Certificate NO. OF CREDITS: 30 and health information documentation. Graduates may be employed by hospitals, physicians’ offices, group practices, multi-speciality clinics, or specialty centers.
BILLING AND MEDICAL RECORD DOCUMENTATION DEPARTMENT OF SURGERY August 1, 2006 . ii Office of Compliance to verify documentation and coding compliance. A number of common problems in compliance have been identified. These include the following;
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