Medical coding is the conversion of diagnosis and healthcare procedures and services into the universally accepted ICD-10 (International Classification of Diseases, CM and PCS) or CPT (Current Procedural Terminology) alphanumeric codes. These diagnoses and procedure codes are abstracted from the medical record documentation provided by a physician. The coding professionals ensure each ICD-10 code is assigned appropriately and correctly. The ICD-10 alphanumeric codes are imperative to the billing process, and allow the facility and physician to create claims that are paid either by the patient or insurance carriers. An inpatient coder is a medical coder that assigns codes to diagnosis and healthcare procedures and services in inpatient facilities.
How would you define standardized terminologies and why are they important? Provide an example in your answer.
As a certified medical coder (CCA 11/2012), I have contributed to the HIMS department by helping code inpatient encounters from patients in the Residential Rehab Unit as well as outpatient encounters from the other clinics at this VA applying the official coding conventions outlined in the International Classification of Diseases 9th revision handbook as well as in the VHA’s Official Coding Guidelines, V11.0 dated August 10, 2011. Having coded many encounters over the past 3 years, I can easily determine the main condition after study that is chiefly responsible for a patient’s admission to the hospital. ICD-9-CM defines this as the primary diagnosis code and I find that it is most important to list this code first in your documentation
Anatomy and physiology are a vital part in the medical coding and billing process. Without knowledge of them the modern day medical coder and biller would experience difficulty taking care of business effectively. The new ICD 10 codes are more elaborate and complex than the ICD 9 codes. Understanding anatomy and physiology will help to eliminate costly mistakes and keep the profit flowing in the right direction.
Medical billers often communicate with physicians and other health care professionals to explain diagnoses or to attain further information by means of phones, email, fax, etc. The biller must know how to read a medical record and be familiar with CPT®, HCPCS Level II and ICD-9-CM codes.
Medical billing codes are used to communicate the diagnosis and treatment of a patient from the healthcare provider to the patient's payer (private insurance, Medicare or Medicaid). Those codes help the payer determine how much to pay the provider for services rendered to the patient. These codes allow for modifiers which describe procedures and services in greater detail. Modifier 22 When a procedure takes longer than it should, the medical coder can use Modifier 22 to indicate the extra work involved. Billers set a standard time interval for each procedure or patient visit.
● Coordinate multiple office functions that focus on computerized scheduling, electronic billing, patient records and charts, data management and finances with a demonstrated knowledge of insurance carriers policies and procedures, medical terminology and CPT/ICD-9 and ICD-10 codes
The use of abbreviations shortens length of many words thus really help healthcare professionals in saving time spent in writing notes. Abbreviations however do not always provide positive contributions due to misconceptions, misunderstandings, and misinterpretations leading to commitment of errors in the practice. Similarities in abbreviations for instance could root to a grave mistake. For instance the q.d. which an inscriber would like to indicate as every day could be erroneously interpreted as q.i.d. which means four times a day. Such error could result to over dosage when a certain medication is taken four times in a day instead of just once. Though some abbreviations can be easily understood clearly and exactly as to what meaning they communicate, the use of abbreviations generally invite error potentials particularly the error-prone abbreviations (ISMP, 2007) which can be best avoided by eliminating abbreviations.
At the end of the day, physicians routinely record their patient notes into a tape recorder or other recording device, depositing the resulting medium at the hospital's transcription department. Since most in-house records departments are not 24/7 operations, there is no action on the patient data until the next morning, when the transcription staff types up the information in the tapes. When the transcription is complete, the st...
A new law will probably be introduced into state legislatures which will govern all contracts for the development, sale, licensing, and support of computer software. This law, which has been in development for about ten years, will be an amendment to the Uniform Commercial Code. The amendment is called Article 2B (Law of Licensing) and is loosely based on UCC Article 2 (Law of Sales), which governs sales of goods in all 50 states. A joint committee of the National Conference of Commissioners on Uniform State Laws (NCCUSL) and the American Law Institute is drafting the changes to the UCC.
...urance provider. The scenario reinforced the urgency to seek reputable agency training with seasoned supervisors who provide good training in diagnosis codes.
Clinical Documentation Improvement ensures that their health care system provides the accurate recording of medical records. The health information management industry (HIM) thrives over the improvements towards clinical documentation as medical assistance validates healthcare and optimizes their medical processing system. Clinical documentation specialist (CDS) is essential in order to alter the medical landscape in a positive measure as they provide detailed documentation and medical coding. Documentation requirements for Health Information Management (HIM) professionals intend on making the healthcare data obtainable from the additional diagnoses, which will require an enhancement of the documentation system. Thus, the ICD-10 is a new tool
What is CAC? CAC is computer-assisted-coding, which is software that recommends codes to users to confirm the results before processing the codes to billing. Computer-assisted-coding is meant to help coders ensure quality of their coding. Many healthcare professionals were concerned that the use of computer-assisted-coding would eliminate the need for professional coders, but were soon put at ease to see that this was simply not the case, as professional coders are still needed to review productivity and accuracy.
Medical Coding and Billing can help doctors by handling all the paperwork that has to be submitted to the insurance companies. They can also help by sending medical bills out to all the patients that have been seen by the doctor.
There many different medical codes such as the International Classification of Diseases (ICD) codes, the Current Procedural Terminology (CPT) codes, and the Healthcare Common Procedure Coding System (HCPCS). ICD codes are the most widely used codes for designating diseases and injuries and are currently a 10 digit numerical code. CPT codes are used to specifically identify medical treatments. HCPCS codes are used to expand CPT codes for nonphysician services and medical equipment. Is is very important for medical coding to be accurate in order for providers to be reimbursed for the proper services provided.
I could volunteer or intern in a type of mental health care facility and maybe even