Many times, a rural provider will see the same type of diagnosis on a daily or weekly basis. Unfortunately, the medical coder will become efficient and fall into the same routine. This could lead them to succumb to the pressure of productivity and quotas. To prevent this, let’s take a another look at the basics of medical coding.
ICD diagnostic coding accurately reflects a healthcare provider’s findings. A healthcare provider’s progress note is composed of four component parts. First comes the patient’s chief complaint, the reason that initiates the healthcare encounter. Second, the provider documents his or her observations. This includes a review of the patient’s history, a review of pertinent medical systems, and a physical examination. Following these, the healthcare provider renders an assessment in the form of a diagnosis, and a plan of care.
Below are a few checklists to help you make sure you’re following the appropriate guidelines when coding:
Documentation — Proper Medical Record:
- Why did the patient present for care?
- What was done?
- Where were the services rendered?
- When is the patient to return, or what is the plan of action?
- Will there be follow-up tests or procedures ordered?
Items to Remember:
- If it didn’t happen, don’t code it.
- Document what you do and do what you document.
- It is not billable, therefore not a reimbursable service, if it is not documented.
- Don’t code symptoms if you have a diagnosis.
- You can code the symptoms if you don’t have a diagnosis.
Ten steps to coding:
- Identify the reason for the visit.
- Consult the alphabetic index.
- Locate the main entry term.
- Read and interpret any new notes listed with the main term.
- Review entries for modifiers.
- Interpret abbreviations, cross references and brackets.
- Choose a tentative code and locate it in the tabular list.
- Determine whether the code is at the highest level of specificity.
- Refer to the front of the book for definitions of colors and symbols.
- Assign the code.
Three reasons for denial:
- Your coding was misinterpreted.
- They unilaterally denied payment.
- You coded it wrong or repeated incorrect coding. Denials lead to auditing.
Ten steps to safety:
- Live happily ever after.
- Collect what you billed.
- Bill what you documented.
- Stay away from creative billing.
- Follow billing & coding guidelines.
- Understand the regulations.
- Document medical necessity.
- Document the procedure.
- Record the visit.
- Perform the service.