...Job description Inpatient Medical Coding Inpatient Medical Coding job involves coding charts for patients whose treatment requires hospitalization for more than 24 hours. Inpatient Medical Coders use the coding systems ICD-9-CM, ICD-10 as well as DRG (Diagnoses Related Groups). Inpatient Medical Coding requires greater knowledge and experience because the groupings and sequencing of codes for specific diagnoses and procedures in a hospital are significantly greater. Daily tasks usually include: • Review patient histories, operations, chart reviews, consultation and discharge summaries to support codes selected for billing. • Utilize ICD-9-CM and/or ICD-10 to select the diagnosis-related group (DRG) assignments for each case. • Identify mistakes in reports. • Enter coding information into electronic billing system. Many Inpatient Medical Coders work for hospitals, although insurance companies and long-term health-care facilities may also employ inpatient coders. They typically must have at least 2 years of experience to be hired and may work at the facility or off-site in their homes. Hours vary based on the employer. Accuracy is critical in this position, as much of a hospital’s revenue depends on the correct coding of the diagnoses, procedures, and treatments administered. Coders often interact with physicians, nurses and other medical professionals in order to select the proper codes. Critical thinking and communication skills, great attention to detail and the ability...
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...2. Patient Check-in and Payment Collection Step 3. Rooming and Measuring Vital Signs Patient Examination and Documentation Step 4. Patient Checkout Step 5. Post-Visit: Coding and Billing Post-Visit: Reviewing Test Results Coding and Reimbursement in Electronic Health Records Computer-Assisted Coding Clinical Tools in the Electronic Health Record Decision-Support Tools Tracking and Monitoring Patient Care Screening for Illness or Disease Identifying at-Risk Patients Managing Patients with Chronic Diseases Improving the Quality and Safety of Patient Care with Evidence-Based Guidelines E-Prescribing and Electronic Health Records Keeping Current with Electronic Drug Databases Increasing Prescription Safety Saving Time and Money LEARNING OUTCOMES After completing this chapter, you will be able to define key terms and: 1. 2. 3. 4. 5. 6. 7. 8. 9. List the five steps of the office visit workflow in a physician office. Discuss the advantages of pre-visit scheduling and information collection for patients and office staff. Describe the process of electronic check-in. Explain how electronic health records make documenting patient exams more efficient. Explain what occurs during patient checkout. Explain what two events take place during the post-visit step of the visit workflow. Describe the advantages of computer-assisted coding. List three decision-support tools the EHRs contain to provide patients with safe and effective health care. List four important safety checks that an EHR’s e-prescribing...
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...and Payment Collection Step 3. Rooming and Measuring Vital Signs Patient Examination and Documentation Step 4. Patient Checkout Step 5. Post-Visit: Coding and Billing Post-Visit: Reviewing Test Results Coding and Reimbursement in Electronic Health Records Computer-Assisted Coding Clinical Tools in the Electronic Health Record Decision-Support Tools Tracking and Monitoring Patient Care Screening for Illness or Disease Identifying at-Risk Patients Managing Patients with Chronic Diseases Improving the Quality and Safety of Patient Care with Evidence-Based Guidelines E-Prescribing and Electronic Health Records Keeping Current with Electronic Drug Databases Increasing Prescription Safety Saving Time and Money LEARNING OUTCOMES After completing this chapter, you will be able to define key terms and: 1. 2. 3. 4. 5. 6. 7. 8. 9. List the five steps of the office visit workflow in a physician office. Discuss the advantages of pre-visit scheduling and information collection for patients and office staff. Describe the process of electronic check-in. Explain how electronic health records make documenting patient exams more efficient. Explain what occurs during patient checkout. Explain what two events take place during the post-visit step of the visit workflow. Describe the advantages of computer-assisted coding. List three decision-support tools the EHRs contain to provide patients with safe and effective health care. List four important safety checks that...
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...Modification- A coding system to classify disease data by disease information or procedure information for clinical information; The coding system assist with reimbursement of services provided by facilities. • The most important aspect of ICD-9 coding system is it defines disease in category allowing medical personnel to determine diagnosis, disorders, and procedures incorporating patient data and can assist in utilization process. CPT- Current Procedural Terminology- CPT is another coding system to document medical services, surgical procedures, and diagnostic procedures. CPT codes are HCPC codes that can identify what has been done to a patient to assist in the diagnosis and prognosis of the patient by physicians, billers, coders, and administrative personnel. • The importance of CPT codes is it is a uniformed coding system for medical personnel to document accurately and maintain records for billing and diagnostic purposes. CMS- Centers for Medicare and Medicaid Services- An agency within the Department of Health and Human Services that administers the Medicare and Medicaid program and standards for HIPPA. • The importance of CMS is it provides the different standards that Medicare and Medicaid providers must adhere to. CMS-1500- Health Insurance Claim Form- Health insurance claim form physicians and facilities use to process procedures and services rendered to patients. • The importance of CMS-1500 is that medical providers are...
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...IN THE United States, primary care remains a medical model. This is in contrast to much of the world, where the 1978 Declaration of Alma-At a which recognized that attaining health for all also requires interaction from social and economic sectors - is considered standard. Today, there is much buzz about patient-centered medical homes, a concept that promises to transform the practice of American medicine. There is much to praise about this most recent iteration of the medical home. But the missing ingrethent in all these definitions and models remains public health. A population focus that addresses the social determinants of health is an essential component of primary health care. In the United States, such a comprehensive approach has been labeled community-oriented primary care. This model is built firmly on the Alma-Ata principles and incorporates a public health approach to health services. Community-oriented primary care organizes the delivery of health services, around a population, not simply a collection of individuals. It identifies a population - most frequently a geographically defined community - and uses epidemiology and interventions to improve community and individual health and well-being. In this model, both individual patients and the community are the foci of the delivery of health services. Primary health care stands at the intersection of personal and population health services. It requires integrating medical models of primary care that are centered on...
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...University of Phoenix Material Accurate Registration Worksheet In 50 to 100 words, explain each step of the medical billing cycle, using Figure 6.7 of Integrated Electronic Health Records as a reference. Your explanations must be in your own words. Step Explanation 1 Pre-registration confirms the patient’s information and helps to identity the patient to ensure the patient safety. This is an important step especial for reoccurring patients... This step also helps with verifying a patients insurance. Pre-registration gives the office ample time to answer questions before they are asked by looking into the EHR. Pre-registration also allows you to see procedures that may require prior authorization (pre-cert). 2 Establish financial responsibility- Establishing financial responsibility is knowing who owes what for a certain doctor’s visits. Once the clinic gathers the pertinent information from the patient, then the biller can then determine which services are covered and allowed under the patient’s insurance plan. Insurance coverage can differ hugely between companies, individual, and plans, The biller needs to make sure each patient’s coverage in order to create the bill correctly. This also goes for prescriptions, some insurance companies do not allow for certain types or prefer generics. 3 Check in patients- Patient check-in and check-out are pretty much straight-at the desk task. When the comes in, First time patients will be asked to fill out paper forms or...
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...and provide a patient’s healthcare history instantly and securely. They contain medical and treatment histories of patients and generally provide all the clinical data that is collected from time to time. An electronic health care record can present a patient’s medical history, diagnoses, allergies, treatment plans, medical visits, costs of treatments, laboratory and radiology reports, test results etc. Advantages of Electronic health Record- Basically speaking, an EHR is a paper chart of a patient’s healthcare details that is readily accessible...
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...Classifications Systems Coding is the same as any other process, there are obligations and rules that must be upheld. You have to complete all the steps in that process to code correctly and produce accurate results. You should not skip steps, every step is there for a reason. As a coder, it is your job to provide correct codes that are not close to the actual code, but codes that are the actual code. I feel that this coder’s approach is unconventional and unethical. Each step included in the process is very important to the outcome of the codes; skipping steps can affect the final results. Coding is a process that takes time and care. This is why the specialist must pay careful attention to each step, if the specialist is not willing to put in that time, then the outcome will most likely contain errors. Leaving out steps can cause many problems. It could result in problems for the coders, the medical facility, and even the patient. If the coder skips a step, he/she might produce the wrong code, which could result in other errors possibly dealing with billing or even prescriptions. The patient could receive the wrong type of treatment if their diagnosis was coded wrong; this could lead to lawsuits and even job loss. I would talk to the specialist about how they code and see if I can deter them from that path with facts. I would explain about the damage that may happen resulting from their negligence. If all of my attempts fail, I will have to report them to my supervisor because...
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...Medical Assistants works closely with physicians mainly in outpatient or ambulatory care facilities, for example medical offices and clinics. Some of the skills required in this profession are excellent interpersonal skills, and an ability to communicate effectively with patients and those you work with. The United States Bureau of Labor Statistics states that, medical assisting is one of the nation’s careers growing much faster than average for all occupations. The field is attributing jobs for growth such as predicated surge in the number of physicians’ offices and outpatient care facilities, technological advancements, and growing number of elderly Americans who need medical treatment (AAMA, 2016). Medical assistants can consist of administrative...
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...MARKETING PLAN FOR ABIGAIL’S MEDICAL BILLING AND CODING Abigail’s Medical Billing and Coding Services, LLC is an accurate, timely and affordabl Here are the major elements of a marketing plan: Executive Summary: The Executive Summary should be a brief summary of the entire marketing plan and include the highlights of each section to be included in your marketing plan. It should also include your Business's Mission (or Vision) Statement. Start with your Mission Statement and use this as a foundation for the rest of marketing plan. Next, work on the rest of the plan, skipping the remainder of this section until the rest of the marketing plan is complete. Your Mission Statement should be a simple paragraph describing your company's values as well as what your company does and who it is. After the rest of the marketing plan is complete, come back and finish the Executive Summary. Product Description: The product description is the detailed description of the products and/or services that you intend to market. Anywhere in length from a few paragraphs to a few pages, use this as an opportunity to communicate your ideas regarding exactly what your product is and how your customers will use it. Market Analysis: The Market Analysis is drawn from in-house or third party Marketing Research and includes: * A description of the target market * Distribution channels with any applicable laws or regulations * The unique positioning of the company and its products...
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...plan is an integral part of North Side’s ongoing efforts to achieve compliance with federal and state laws relating to billing for clinical services. The Plan creates a comprehensive and centralized system of oversight for bill coding, education, chart review, reporting and discipline (“Discipline,” as used throughout this policy shall include all steps described in the Human Resource policy manual and faculty policies and regulations including, without limitation, termination and tenure revocation). This Plan provides for oversight by a Compliance Program Medical Director and Compliance Officer. Although the intent is to encourage compliance through a centralized audit system, it remains the responsibility of each individual involved with the billing process, from physicians and other providers to clerical staff, to comply with the law. The purpose of this Plan is to ensure that clinical services are adequately documented and that properly coded bills are submitted only for documented services. This Plan is to be read in conjunction with and is an integral part of the University of Rochester Medical Center Compliance Plan, which is set forth in a separate document. In addition, it is anticipated that individual departments of the University will create specialty-specific billing compliance plans, which will be subject to review by the Compliance Program Medical Director and Compliance Officer. The University acknowledges that this plan is only the beginning of its efforts to...
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...here are a number of steps to the Medical documentation process. here are 6 key steps from M-scribe Medical Billing. patient check-in, insurance eligibility and verification, coding of diagnosis procedures and modifiers, charge entry, claim submissions, and lastly payment posting. (1) According to Crozer Keystone Health System medical documentation is very important and is required because of the time old saying "if its not documented then it never happen". (2) Documenting the medical record correctly can be very helpful in case of things such as a law suit. Medical Documentation is very important when it comes to billing and coding. Here are some general principles of medical documentation: 1. The medical record shall be complete and...
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...five key components of a health record. Additionally, include a 50- to 100-word description of each component. Support your descriptions using your assigned readings. |Component of the health record |Description | |Patient Management |Required for patient registration, admission, transfer and discharge functionality. | | |Patient registration includes key patient information such as demographics, insurance | | |information, contact information etc. | |Clinical History...
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...Billing Memo This memo is to remind the office of the important of documentation of coding and coding. If something has not been documented it does not happen then we can’t be billed for those services. There are minimum documentation requirements that are needed for reimbursement. Within documentation there are general principles that comes along with documentation. They are as followed chief complain of the patient on their time of visit. A relevant history of the patient. If any physical exam were done to that patient at the time of visit. Those findings with need to have documentation. Any diagnostic testing that has been order by the provider. The reason why the testing was of medical necessity. There also needs to be documentation of the assement of the patient. As well as if a form of diagnosis has been given by the provider to the patient. A plan of care is also needed for documentation and any recommendation of care. Along with the length of the visit with the health care provider. If counseling and or coordination have been provided to the patient. The finally requirement for reimbursement is the date of service that the patient was seen by the provider. As well as the legible identify of the health care provider. Along with those requirements I would to inform you of the electronic solutions that exist that can help ensure. Accurate evaluation and management coding with in our office. The first solution is the use of an electronic superbill. It’s of great important...
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...Running head: UNIT 1 INDIVIDUAL PROJECT Kimberly Young American Intercontinental University Unit 1 Individual Project HLTH250-1002B-01 Introduction to Coding and Billing May 2, 2010 The SOAP (subjective, objective, assessment/analysis, plan) is used to help medical professionals collect and organize medical information on patients (SOAP format, 2009). This format is used to document data in a clear and well organized structure. S – 47 YO male PT with C/C of pain and burning in the LUQ. The patient states that it seems to get worse after alcohol consumption. PT is suffering from LOA, nausea, and diarrhea. PT is C/O of pain in the lower lumbar area that sometimes gets worse after food consumption. States this has been occurring for four weeks or more. The PT has NKA. This is the subjective data. It includes all the things the patient has stated is bothering them. Some of the items that are included in this area are the presenting concern, history of concern, allergies. O – VS appear to be erratic with fever, the PR is high, and PT has extremely low BP. CBC done with WBC very high. Jaundice is evident on PT. Lungs clear. Pain in LUQ obvious when examined. PT is also C/O swelling in ankles and dizziness. Denies dysuria. Infection is obvious. This is the objective data. It contains the observations made by the doctor during examination. Some of the information included in this area is the patient’s vital signs, general appearance...
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