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Chapter 10

Chapter 10. Coding for Medical Necessity. Coding for Medical Necessity. The next step in learning to code correctly is to choose diagnoses and procedures/services from a case and link each procedure/service. Coding for Medical Necessity.

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Chapter 10

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  1. Chapter 10 Coding for Medical Necessity

  2. Coding for Medical Necessity • The next step in learning to code correctly is to choose diagnoses and procedures/services from a case and link each procedure/service.

  3. Coding for Medical Necessity • This chapter requires you to review case scenarios and patient reports to decide the right diagnoses and procedures/services to be coded, and medical necessity issues.

  4. Questions for Consideration • Does this diagnosis or condition support a procedure or service provided during this encounter? • Did the provider prescribe a new medication or change a prescription for a new or existing diagnosis or condition?

  5. Questions for Consideration • Are positive diagnostic test results documented in the patient record to support a diagnosis or condition? • Did the provider have to consider the impact of treatment for chronic conditions when treating a newly diagnosed condition?

  6. Coding and Billing Considerations • You should also incorporate the following as part of practice management • Completion of an Advance Beneficiary Notice (ABN) when appropriate • Implementation of an auditing process

  7. Coding and Billing Considerations • Review of local coverage determinations • Complete and timely patient record documentation • Use of Outpatient Code Editor (OCE) Software

  8. Coding and Billing Considerations • The following characteristics are associated with patient record documentation in all health care settings. • Documentation should be generated at the time of service or shortly thereafter.

  9. Coding and Billing Considerations • Delayed entries within a practical time frame (24 to 48 hours) are acceptable for purposes of clarification, corrections of errors, addition of information not initially available.

  10. Coding and Billing Considerations • The patient record cannot be altered: • Corrections or additions to the patient record must be dated, timed, and legibly signed or initialed • Patient record entries must be legible • Entries should be dated, timed, and authenticated by the author

  11. Coding and Billing Considerations • Medical practices and health care facilities should regularly participate in an auditing process • Allows for review of patient records and CMS-1500 or UB-92 claims to evaluate coding accuracy and completeness of documentation

  12. Codingand Billing Considerations • Local coverage determinations specify under what clinical circumstances a service is covered and correctly coded • OCE • Software that edits outpatient claims submitted by hospitals, home health agencies, and other facilities

  13. Coding from Case Scenarios • Case scenarios are a summary of medical dates from patients’ records • Introduces students to the process of abstracting diagnoses and procedures

  14. Coding from Case Scenarios • Step 1 • Read case scenario and look up any words you don’t understand • Step 2 • Reread • Highlight diagnoses and symptoms • Those that support medical necessity of the procedures performed

  15. Coding from Case Scenarios • Step 3 • Code documented diagnoses, symptoms, procedures, signs, health status, and services • Step 4 • Assign any modifiers that are appropriate

  16. Coding from Case Scenarios • Step 5: • Identify primary condition • Step 6: • Link any procedure or services that were provided to the diagnosis to show medical necessity

  17. Coding from Patient Reports • Services, diagnoses, and procedures • Chosen and coded from the clinic notes, diagnostic reports, and the consultation reports

  18. Secondary Purposes • Patient records do not relate directly to patient care, and they include: • Evaluating quality of patient care • Providing information to third-party payers for reimbursement • Providing data for use in education, clinical research, and other uses

  19. Clinic Notes • There are two major formats that health care providers use for documenting clinic notes: • Narrative clinic notes • SOAP notes • Written in paragraph format

  20. SOAP Notes • Written in outline format • SOAP: • Subjective • Objective • Assessment • Plan

  21. SOAP Notes • Subjective • Part that contains the chief complaint • Objective • Contains documentation of measurable observations made during the physical examination and diagnostic testing

  22. SOAP Notes • Assessment • Contains diagnostic statement and may also include physician rationale behind diagnosis • Plan • Statement for physician’s plans for work-up and medical management of the case

  23. Operative Reports • Narrative of minor procedures that may have been performed in a physician’s office, to a more formal report by the surgeon • Required by hospitals and ambulatory surgical centers

  24. Information Contained in Outline Forms • Date of surgery • Patient identification • Pre- and postoperative diagnosis(es) • List of the procedure(s) performed • Name of primary and secondary surgeons who performed surgery

  25. The Body of the Report • Positioning and draping of patient for surgery • Achievement of anesthesia • Detailed description of how the procedure(s) were performed • Identification of abnormalities found during the surgery

  26. The Body of the Report • Description of how homeostasis was obtained and closure of surgical site(s) • Condition of patient when they left the operating room • Signature of surgeon

  27. Procedure for Coding Operative Reports • Step 1 • Make a copy of report • Step 2 • Carefully review all procedures performed • Step 3 • Read body of report and make notes of procedures that need to be coded

  28. Procedure for Coding Operative Reports • Step 4 • Identify main terms and subterms for procedures to be coded • Step 5 • Underline and research any terms in the report that you cannot define

  29. Procedure forCoding Operative Reports • Step 6 • Locate main terms in CPT/ index • Step 7 • Research all the suggested codes

  30. Procedure forCoding Operative Reports • Step 8 • Return to index if you cannot find a code that matches the description of the procedures performed • Step 9 • See if there are any modifiers that need to go on the procedures to explain it fully

  31. Procedure for Coding Operative Reports • Step 10 • Code postoperative diagnosis • Step 11 • Review code options with the physician • Step 12 • Assign final codes and any addendum the physician added to the original report

  32. Procedure for Coding Operative Reports • Step 13 • List most significant procedure performed first • Step 14 • Be sure to destroy your copy of the report

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