Medical coding certifications

1. Chapter 2The Health Record as the Foundation for Coding

2. Learning Objectives • Explain the purpose of the various forms or reports found in a health record • Define “principal diagnosis” • Define “principal procedure” • Identify reasons for assigning codes for other diagnoses • List basic guidelines for reporting diagnoses/procedures • Identify which types of documentation are acceptable to use when assigning codes • Explain the physician query process

3. The Health Record • One for each patient • Documents health history • Timely • Documentation in record should: • Identify patient • Support diagnosis or reason for encounter • Justify treatment • Document results • Once go through Medical coding training in india

4. The Health Record • Describes the patient’s health history • Serves as a method for clinicians to communicate regarding the plan of care for the patients • Serves as a legal document of care and services provided • Serves as a source of data • Serves as a resource for health care practitioner education

5. The Health Record • Current format of Health Records • Electronic • Paper (traditional) • Electronic and paper “hybrids” • Once check it out

6. The Health Record • General Principles of Medical Record Documentation • Medical Records should be complete and legible • The documentation of each patient encounter should include: • Reason for encounter and relevant history • Physical examination findings and prior diagnostic test results • Assessment, clinical impression and diagnosis • Plan for care • Date and legible identity of the observer

7. The Health Record • General Principles of Medical Record Documentation • The rationale for ordering diagnostic and ancillary services • if not documented should be easily inferred • Past and present diagnoses should be accessible for treating and/or consulting physician • Appropriate health risk factors should be identified • Patient’s progress, response to changes in treatment, and revision of diagnosis should be documented

8. The Health Record • General Principles of Medical Record Documentation • Current Procedural Terminology (CPT) and International Classification of Diseases, 9th Revisions, Clinical Modification (ICD-9-CM) codes should be supported by documentation

9. Sections of the Health Record • Administrative Data • Demographic • Personal • Consents • Medical coding training in india

10. Sections of the Health Record • Clinical Data • Emergency room documentation • Admission history and physical (H&P) • Physician orders • Progress notes by health care providers • Anesthesia forms • Operative notes

11. Sections of the Health Record • Clinical Data • Recovery room notes • Consultations • Laboratory test results • Radiology test results • Miscellaneous ancillary reports • Discharge summary

12. Sections of the Health Record • Clinical Data • Requirements for data mandated by: • Joint Commission • Medical Staff By-laws • Federal Government Guides • UHDDS Discharge Data Set • DOB • NPI

13. Sections of the Health Record • Demographic Data • Patient identification • Personal identification elements • DOB • Name some personal identification elements

14. Sections of the Health Record • Emergency Record • Mini medical record • Chief complaint • Other medical services during visit • Working diagnosis • Discharge or transfer disposition • medical coding certification in india

15. Sections of the Health Record • Admission History and Physical (H&P) • Chief complaint • History of present illness • Past medical history • Family medical history • Social history • Review of systems • Physical exam • Impressions and plans

16. Sections of the Health Record • Physician Orders • Attending Physician • Consultants • Written or verbal List some required elements of a written physician order

17. Sections of the Health Record • Anesthesia Forms • Pre-anesthesia • Post-anesthesia • Anesthetic agent used • Amount • Administration • Duration • Blood loss • Fluids

18. Sections of the Health Record • Consultations • Requested by attending physician • May be used to assess surgical risk • Surgical clearance • Within progress note or separate form

19. Sections of the Health Record • Laboratory, Radiology, and Pathology reports • Electronic or paper • Medical coding training in india

20. Sections of the Health Record • Discharge Summary • History of present illness • Past medical history • Findings • Lab data • Other treatments or procedures performed • Final diagnosis • Discharge information

21. UHDDS Reporting Standards for Diagnosis and Procedures • Information extraction • Principal diagnosis • Other, secondary diagnoses • Principal procedure • Secondary procedures

22. UHDDS Reporting Standards for Diagnosis and Procedures • Principal Diagnosis • Defined: the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care • Key to appropriate MS-DRG reimbursement

23. UHDDS Reporting Standards for Diagnosis and Procedures • Other Reportable Diagnoses • Conditions that coexist at the time of admission • Conditions that develop after admission • Conditions that affect the treatment • Conditions that affect the length of stay