By Michelle A. Green
3-2-1 CODE IT! is your accomplished studying source for coding. This e-book combines ICD-9-CM, CPT, and HCPCS point II coding strategies into one handy package deal and provides a degree of element compatible for starting and more matured coders alike. while you are able to earn a coding credential, this ebook will proceed that will help you arrange and perform. The booklet contains an outline of coding structures, profession possibilities for coders, the significance of becoming a member of specialist businesses and acquiring credentials, the effect of operating with different coding execs, and the way to boost possibilities for profession development.
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Additional info for 3-2-1 Code It! , Second Edition
09 for the “skin incision” procedure. ” Although the patient has an open fracture, the physician did not perform an open reduction procedure. ) In this case, the coder incorrectly “assumed” that an open reduction was performed because the patient’s open fracture was treated. 25) was submitted to the third-party payer, reimbursement would be $5,000. 05) is submitted, reimbursement is just $3,000. 16 Part I Coding Overview When coders have questions about documented diagnoses or procedures/services, they should use a physician query process to contact the responsible physician to request clarification about documentation and the code(s) to be assigned.
If a provider performs a service but doesn’t document it, the patient (or third-party payer) can refuse to pay for that service, resulting in lost revenue for the provider. In addition, because the patient record serves as an excellent defense of the quality of care administered to a patient, missing documentation can result in problems if the record has to be admitted as evidence in a court of law. Chapter 1 Overview of Coding 15 EXAMPLE MISSING PATIENT RECORD DOCUMENTATION: A representative from XYZ Insurance Company reviewed 100 outpatient claims submitted by the Medical Center to ensure that all services billed were documented in the patient records.
A manual record is paper-based, while an autogenerate paper-based records. When mated record uses computer technology. A hybrid record consists viewed on a computer monitor, they of both paper-based and computer-generated documents, which are considered to be a sort of EHR. , transcribed reports and automated laborain a format that is easily retrievable tory results). A variety of formats are used to maintain manual and viewable by users. records, which include the source-oriented record (SOR), problemoriented record (POR), and integrated record.