Chapter 3 - The Coding Process Flashcards
Terminology
Alphabetic Index
The section of a code book showing all codes, from A to Z by the short description.
Alphanumeric
Containing both letters and numbers
Coding Process
The sequence of actions required to interpret physician documentation into the codes that accurately report what occurred during a specific encounter between Health care professional and patient.
Linking
Confirming medical necessity by pairing at least one a diagnosis code to at least one procedure code.
• multiple procedure codes can link to one diagnosis code, and multiple diagnosis codes can link to one procedure code. But there must be at least one of each to support the encounter. (P. 47)
Main section
The section of the CPT code book listing all of the coded in numeric order.
Notations
Alerts and warnings that support more accurate use of codes in a specific code set.
Official Guidelines
A listing of rules and regulations instructing how to use a specific code set accurately.
Symbols
Mark, similar to emojis, that provide additional direction to use codes correctly and accurately.
Tables
The section of the ICD-10-PCS code book listing all of the codes in alphanumeric order, based on the first three characters of the code.
Tabular list of diseases and injuries
The section of the ICD-10-CM code book listing all of the codes in alphanumeric order.
The coding process
The sequence of actions required to interpret physician documentation into the codes that accurately report what occurred during a specific encounter between Healthcare professional and patient
ACTION 1
Abstract the documentation
- Read completely through the documentation for the encounter, from beginning to end.
- re-read the documentation and identify the main words regarding the diagnoses (why) and procedures (what) of the encounter.
- if the patient was injured, you will need to identify the external causes (how and where) as well.
ACTION 2
Query, if necessary
- Make a list of questions you have regarding:
* unclear
* missing
* contradictory - information necessary to code.
- query the healthcare provider who cared for the patient.
- never assume or guess.
- use non leading questions.
ACTION 3
Code the diagnosis or diagnoses
Code each diagnosis and/or appropriate signs or symptoms describing why the health care provider treated this patient during this encounter, as documented in the notes, to tell the whole story.
Use the best, most accurate code or codes available based on that documentation.
ACTION 4
Code the procedure or procedures
Determine for whom you are reporting: physician, outpatient facility, or inpatient facility. This way, you will know which code set to use: CPT or ICD-10-PCS.
Code each procedure, service, or treatment, as stated in the notes, describing what the provider did for the patient during this encounter.
ACTION 5
Confirm medical necessity
Ensure that each and every procedure code is supported by at least one diagnosis code to verify medical necessity.
ACTION 6
Double-check your codes
Begin to build the Habit, right now, of reading slowly, carefully, and completely.
There are so many times, when reviewing a coding error, we have heard, “Oh, I can’t believe I didn’t see that!”
It is better for you to find and correct your own mistakes then have anyone else find your mistakes and suffer the consequences.
The Alphabetic Indexes
Diagnoses (why)
ICD-10-CM code set
The Alphabetic Indexes
Physicians services (what)
CPT code set
The Alphabetic Indexes
Outpatient facility Services (what)
CPT code set
