1 - 1 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. You Code It! A Case Studies Workbook 2 nd Edition By Shelley C. Safian, MAOM/HSM, CCS-P,

Slides:

Advertisements

Similar presentations

Managing Information. Why is record Keeping Important? Legal Protection Legal Protection Memory/Communication Aid Memory/Communication Aid Legal requirement.

Advertisements

Applications of Health Informatics.  John Graunt began the statistical study of disease in the early 17 th century  1837 William Farr wanted adoption.

© 2009 by The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Career Education Chapter 7: Creating Claims Computers in the Medical Office.

Coding for Medical Necessity

15 The Health Record.

© 2009 by The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Career Education Computers in the Medical Office Chapter 1: The Medical Office.

CHAPTER © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 1 The Medical Billing Cycle.

Copyright © 2008 Delmar Learning. All rights reserved. Chapter 4 Life Cycle of an Insurance Claim.

The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 2 Introduction to Coding and CPT Copyright © 2009 by The McGraw-Hill.

POH/DMC UROLOGY Grand Round Conference Presented by: Spectrum Billing Technologies, LLC.

CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 9 Checkout Procedures.

20 CPT and HCPCS Coding.

CHAPTER © 2013 The McGraw-Hill Companies, Inc. All rights reserved. 7 Creating Claims.

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Introduction to CPT Chapter Six.

©2011 by The McGraw-Hill Companies, Inc. All rights reserved. The Complete Procedure Coding Book 2 nd Edition By Shelley C. Safian, MAOM/HSM, CCS-P,

The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 4 Coding Circulatory Conditions Copyright © 2009 by The McGraw-Hill.

The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 14 Coding Medical Supplies, DME, etc. Copyright © 2009 by.

INTRODUCTION TO ICD-9-CM

INTRODUCTION TO ICD-9-CM PART TWO ICD-9-CM Official Guidelines (Sections II and III): Selection of Principal Diagnosis/Additional Diagnoses for Inpatient.

Medical Coding Chapter 16 Medical Assisting

Medical Assisting Chapter 16

The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 13 HCPCS Level II Coding Copyright © 2009 by The McGraw-Hill.

The Complete Procedure Coding Book By Shelley C

The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 15 HCPCS Level II Modifiers Copyright © 2009 by The McGraw-Hill.

Medical Assisting Review Passing the CMA, RMA, and NHA Exams Fourth Edition © 2011 The McGraw-Hill Companies, Inc. All rights reserved. Chapter 14 Basic.

DOCUMENTATION GUIDELINES FOR E/M SERVICES

The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 3 General Guidelines and Notations Copyright © 2009 by The.

The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 3 General Guidelines and Notations Copyright © 2009 by The.

The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 9 Coding Obstetrics and Gynecology Copyright © 2009 by The.

The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 10 Coding Congenital and Perinatal Conditions Copyright ©

The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 4 Evaluation & Management Codes Part 1 Copyright © 2009 by.

The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 5 Coding Neoplasms Copyright © 2009 by The McGraw-Hill Companies,

The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 2 Introduction to ICD-9-CM Book Copyright © 2009 by The McGraw-Hill.

16 Medical Coding.

The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 2 Introduction to ICD-9-CM Book Copyright © 2009 by The McGraw-Hill.

Copyright © 2009 by The McGraw-Hill Companies, Inc. All Rights Reserved. McGraw-Hill Chapter 7 Introduction to Practice Partner Electronic Health Records.

The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 4 Coding Circulatory Conditions Copyright © 2009 by The McGraw-Hill.

The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 16 ICD-9-CM Volume 3 Procedure Codes Copyright © 2009 by The.

Medicare Documentation & ICD-9-CM Coding Presented by Rhonda Anderson, RHIA President Anderson Health Information Systems, Inc

Professor Kristy K. Taylor.  Job Functions:  Roles and qualities of an Office Manager  Motivate and Mentoring Team Members  Certification  The Office.

Define: charting diagnosis discharge summary report electronic medical record health history report Informed consent medical record medical record format.

The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 1 Introduction to Diagnosis Coding Copyright © 2009 by The.

7-1 Chapter 7 Ambulatory Healthcare © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill.

Chapter 1 The Insurance Billing Specialist. Careers in Health Care.

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Chapter 8 Creating Templates.

The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 7 Coding Burns Copyright © 2009 by The McGraw-Hill Companies,

Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights.

The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 5 Evaluation & Management Codes Part 2 Copyright © 2009 by.

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Chapter 6 The Office Visit.

The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Appendix B ICD-10-PCS Copyright © 2009 by The McGraw-Hill Companies,

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.

The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 7 Surgery Coding: Part 1 Copyright © 2009 by The McGraw-Hill.

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes.

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.

The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 11 Coding Infectious Diseases Copyright © 2009 by The McGraw-Hill.

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.

Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education.

The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 3 Introduction to Modifiers Copyright © 2009 by The McGraw-Hill.

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Chapter 5 The Patient Chart.

Copyright © 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Coding for Medical Necessity Chapter 10.

Medical Documentation CHAPTER 17. Purposes of Documentation  Communication  Most patients receive care from more than one source  Allows all health.

Click to begin. Click here for Bonus round OIG Issues Medicare & Medicaid General 100 Point 200 Points 300 Points 400 Points 500 Points 100 Point 200.

Evaluation & Management Codes

Category II & Category III

How Physicians Get Paid: It's as Easy as: CMS, RVUs, ICD-10, and CPT

Presentation transcript:

1 - 1 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. You Code It! A Case Studies Workbook 2 nd Edition By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 1 How To Abstract Notes

1 - 2 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Introduction ·The most efficient and effective way to code an encounter between a health care professional and a patient is to review the physician’s notes for that encounter.

1 - 3 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Steps To Coding 1.Read through notes completely 2.Highlight key words 3.List anything missing, incomplete, or confusing. Query the physician.

1 - 4 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Steps To Coding 4.Code the diagnoses, signs, and/or symptoms as stated by the physician. 5.Code the procedures, services, and treatments provided at this visit. 6.Link every procedure code to at least one diagnosis code.

1 - 5 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Steps To Coding 7.Double-check your work! Back code to ensure the code descriptions match what the physician wrote in the notes. Carefully check your data entry to ensure to no typos!

1 - 6 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Medical Necessity ·Medical necessity is the assessment that the provider was acting according to standard practices in providing a procedure or service for an individual with a specific diagnosis.

1 - 7 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Medical Necessity ·DIAGNOSIS codes explain ·WHY the physician provided treatment; ·WHY the patient needed the services; ·WHY the insurance carrier should pay for it all. ·Diagnosis codes EXPLAIN the medical necessity of the service.

1 - 8 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Medical Necessity ·Diagnoses, signs, and symptoms are coded from ·ICD-9-CM volumes 1 and 2 NOTE: On October 1, 2013, this will be replaced with ICD-10-CM

1 - 9 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Procedures ·Procedures, services, and treatments are coded from: ·CPT ·HCPCS Level II ·ICD-9-CM volume 3* *NOTE: On October 1, 2013, this will be replaced with ICD-10-PCS

©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Physician Notes ·SOAP notes ·Subjective Objective ·Assessment Plan ·Narrative notes ·Procedure notes/Operative notes

©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Interpreting Notes Read the complete documentation: Roseanne Tanner, a 23-year-old female, came to see Dr. Matlock with a complaint of arm pain. After a history and exam, he took an x- ray, and diagnosed her with a simple fracture of the ulna, right side. He applied a cast.

©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Interpreting Notes Identify key words: Roseanne Tanner, a 23-year-old female, came to see Dr. Matlock with a complaint of arm pain. After a history and exam, he took an x-ray, and diagnosed her with a simple fracture of the ulna, right side. He applied a cast. Diagnosis: WHY Procedures: WHAT

©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Interpreting Notes Missing information(?): Query the physician Diagnosis: Exactly what portion of the ulna bone was fractured? HOW and WHERE did she get her injuries (for the E-codes)?

©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Interpreting Notes Missing information(?): Query the physician. Procedures: Was the patient new or established? How many views of the arm x-ray were taken?

©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Interpreting Notes Find the diagnosis code or codes: Simple fracture of the ulna, shaft Fall from ladder E881.0 At home E849.0

©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Interpreting Notes Find the procedure code or codes: Office visit, new patient, expanded problem focused X-ray, forearm, 2 views Closed treatment of ulnar shaft fracture; without manipulation 25530

©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Chapter Summary ·Use the following chapters to practice your coding skills for: ·Diagnosis coding ·Procedure coding ·DME, pharmaceutical, and other HCPCS level II coding ·All of the above!

©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Please Note! The case studies in this chapter and this entire book are real patient records, written by various physicians and health care professionals around the country. Unlike many coding exercises, this documentation may not contain ALL of the details you need to determine the code…just like in real life. This is designed to help you begin your transition from classroom to career. Therefore, you may need to ‘query the physician’ [in class that would be your instructor]. You may need to research some procedures or determine inclusive signs and symptoms. All great rehearsal for your future!