Coding Flashcards
Which numbers do we look at on the coding tab on DocuTAP?
The last two numbers (e.g., 03, 04, 05)
Which codes do we use?
Only those whose last two digits are 3, 4, or 5.
What does the second to last number tell us?
Whether a patient is new or established.
What will the second to last number be if a patient is new?
0
What will the second to last number be if the patient is established/returning?
1
How is the calculation done to determine if a patient is new or returning?
Docutap automatically calculates it
What coding status do new patients start off at?
03
What criteria can move a pt from a 3 to a 4?
1) IV
2) CT
3) US
4) Any fracture except fingers and toes
5) IM treatment AND any diagnostic test
6) The following diagnoses:
- Common: Pneumonia, Elevated BP, Hematuria, Sciatica
- Visceral: Headache, Chest Pain, Abdominal Pain
- Constitutional: Fatigue, Fever, Lightheadedness, Dizziness, Near-Syncope, Syncope, Weakness
What code will a returning patient default to?
14
In what situations will a returning patient reduce from a code of 14 to a code of 13?
1) Asymptomatic mediation refill (if symptomatic, they remain 14)
2) Patients during a follow-up visit for a symptom that has improved from their last visit (if pt has another complaint, no improvement, or worsened symptoms, he/she remains a 14).
What is used to determine if a returning patient is symptomatic?
1) Physical presentation
2) Vital signs
What 5 criteria can elevate a patient to a code of 05 or 15?
1) Patient received Valium at TAUC.
2) Patient received morphine at TAUC.
3) Patient has unstable vital signs.
4) Patient sent to the hospital (regardless of whether by ambulance or private vehicle).
5) Patient given Epi or Vasoactive medications (Nitroglycerin or Oral BP medications Lisinopril or Clonidine)
What would you code this patient and why?
New pt presents with hand pain and receives Toradol and a hand X-ray. The X-ray comes back normal and the pt is discharged with a diagnosis of hand contusion.
04
0: This is a new pt.
4: Pt was given Toradol (IM therapy) along with an X-Ray (diagnostic test)
What would you code this patient and why?
Returning pt comes in with a rash which is improving, but won’t go away. She was originally seen at another urgent care 3 days ago when the rash started.
14
1: Returning pt.
4: Not reduced to 3 because pt is not following up or requesting a medication refill. Nor upped to 5 because she does not meet 5 for a 5 requirements.
What would you code this patient and why?
Returning pt presents with excruciating low back pain which began after he was lifting furniture and twisted at home. He can’t stand up on his own, and the provider orders 5 mg of Diazepam. No X-Rays were ordered due to the absence or traumatic mechanism, and the pt eventually has relief with the medication and is discharged home.
15
1: Returning pt.
5: Was given Valium (one of the 5 for 5)
