The Coding Primer幻灯片.pptVIP

The Coding Primer CPG Thursday October 2007 Coding: “Can’t Live With It. Can’t Live Without It.” Coding is important because it builds the electronic health record. It is the language we use to collect our fees. It has become and will become even more the means by which we will be alotted cash and manpower. How are we doing now? 573 encounters audited by our coders in August 2007. 84.05% Diagnosis correct. 74.57 % Eval/management codes correct. 67.18 % CPT codes correct. Document what you performed. Method / Location / Quantity / Size / Layers / Time frames. 51 % of encounters had errors found! In general… Code only what you know. If the diagnosis is “likely” or rule-out code for the symptoms the patient is having. E.g. CHF rule out can be coded as lower leg swelling. Don’t code for resolved conditions. Use the v67 series for follow up exams. List complicating factors. Comorbidities, other chronic conditions the patient may have, adverse effects of medications that may be indicated. Helps to determine the complexity of the decision making process you are making. In general… Try to be clear about taking intermediate steps to address a patient’s condition. This can boost the complexity of the condition to the coder. Trying first physical therapy, nsaids prior to surgical consideration for example. Use the “50%” button as the exception, not the rule. In general… Be specific about reviews of labs or xrays. Labs reviewed with patient showed elevated wbc indicating sepsis or inflammation. If a patient is following up blood pressure check tell what was wrong with the blood pressure to begin with. Be sure to add the nurse, MA or corpstaff as an additional provider to help show clinic workload. In general… Medical necessity should drive ordering of labs or other diagnostic studies. Write a story that tells why these labs need to be done. The complexity of the office visit is based on the story not on the fact that so many labs were ordered. When applicable, c