Coding & Coding Guidelines Flashcards
What does Documentation include?
The reason for encounter, history, physical exam, diagnostic/lab tests, and a treatment plan. It should also validate the appropriateness of the medical services.
What is Medical Necessity?
The process of providing diagnosis codes that support the services rendered to the patient; coding for medical necessity involves associating applicable diagnosis codes to service/procedure codes within the billing software, which is referred to linking/linkage.
What must each patient encounter have?
The reason for visit and medical necessity.
What does SOAP stand for?
Subjective, Objective, Assessment, Plan
What does the Subjective in SOAP mean?
Symptoms or history of the condition using the patient’s own words, describes improvement or decline of the condition since the last visit, explanations for any gaps in treatment, and the patient’s compliance with the provider’s recommendations.
What does the Objective in SOAP mean?
Vital signs, physical examination findings, laboratory, and other diagnostic data, imaging results, and documentation from other clinicians.
What does the Assessment in SOAP mean?
The diagnostic impression or working diagnoses based on the subjective complaints and objective findings.
What does the Plan in SOAP mean?
Procedure or plan for treatment including treatment frequency, duration, and expected outcomes and goals of treatment. the plan often includes medication, referrals, and patient education and counseling.
What does the Medical Record consist of?
Administrative data and clinical documentation
What is Clinical Documentation?
Information recorded in the medical record pertaining to the health status of a patient as determined by a health care provider.
What is the key to coding?
Clinical Documentation
What are some typical types of documentation?
History & Physical, Progress Notes, Consultation Report, Orders, Operative Reports, Radiology/Nuclear Medicine Reports, and Discharge Summary
What is a History & Physical(H&P)?
Information pertaining to the patient’s health history and current condition.
What is a Progress Note?
Documentation of a patient encounter which includes history, exam, and medical decision-making.
What is a Consultation Report?
This type of report includes physical examination and test results, along with the consultant’s expert opinion about the patient’s condition.
What are Orders?
A request made by the provider to receive services, labs, diagnostic tests, therapy, or medication. The order includes a diagnostic statement to indicate why the order is needed. Without an order these services cannot be performed.
What is an Operative Report?
Surgeon dictated report containing details about the procedure performed, why it was necessary, operative findings, and the condition of the patient at the end of the procedure.
What is a Radiology/Nuclear Report?
A report written by the radiologist which describes the findings and assessment of radiology films or nuclear medicine tests.
What is a Discharge Summary?
A summary of an inpatient or surgical encounter which includes the last face-to-face encounter, a physical exam, review of medication, and any discharge orders for home health or physical therapy, and any other instructions for the patients. This summary report is often used by the primary care provider(PCP).
What are the Standard Code Sets used for Billing?
Terminology Standards
What are Code Sets used for?
To classify medical treatments, tests, procedures, supplies, and equipment, and diagnoses identified in the medical records.
Other than billing, what are code sets used for?
Research and Population Health Management
Who regulates Code Sets?
HIPAA Administrative Simplification
What are the different Code Sets?
ICD-10, CPT, HCPCS, CDT, and NDC
