Professional Documents
Culture Documents
Records
Yvette Pawlowski
Spring 2015
Table of Contents
Types of Coding
Diagnostic Coding
Procedural Coding
Translating healthcare procedures (services and treatments) into code using any of the
following code sets:
RECORD
TYPE
Physician
Office
Ambulatory
Yes
(Outpatient)
Surgery
Emergency
Yes
Room
Inpatient
Yes
(hospital coder)
Yes
NO
Yes
NO
NO
Yes
Physician
Office
Ambulatory
(Outpatient)
Surgery
Emergency
Room
Inpatient
Abstracting/Coding Records
Step-by-Step Method of Abstracting/Coding Records
The Face Sheet or Registration Record is the front page of the medical record. It
contains basic patient identification data, insurance information, and sometimes
clinical data such as the admitting and final diagnoses.
What to look for:
a. Length of stay (dates of treatment, admission date, discharge date), sex,
age, and admitting diagnosisall of which can impact the complexity or
assignment of the diagnosis
b. Prospective payment system payers (e.g., Medicare or Medicaid), which
may raise compliance and reimbursement issues
Step B: Review History and Physical, Emergency Department Report, and/or Consultants
Report
Inpatient Records or Ambulatory Surgery will have a History and Physical, which
is generated by the attending physician. It contains the chief complaint (CC) of
the patient, history of the present illness (HPI), review of systems (ROS), and
personal, family, and social history (PFSH). This contains subjective data
collected from the patient to begin the process of diagnosis by the physician. The
physical examination (PE) includes a system-by-system physical examination by
the provider to collect objective data on the patients condition.
o Review the H&P to determine the chief reason(s) for admission and to
begin to get a feel for the possible options for the principal diagnosis (i.e.,
the condition, after study, chiefly responsible for occasioning the
admission of the patient to the hospital for care) and secondary
diagnoses. Review the history for secondary diagnoses such as
comorbidities and other diagnoses affecting patient care that need to be
reported per Uniform Hospital Discharge Data Set (UHDDS) rules. Note
that UHDDS rules are included in the ICD-9-CM and ICD-10-CM Official
Coding Guidelines under Sections II, III and IV, and Appendix I. Note, the
UHDDS definition of principal diagnosis applies only to inpatients in
acute, short-term, long-term care and psychiatric hospitals.
o Review the physical examination for abnormal findings.
UHDDS Rules (Definitions): The UHDDS definitions are used by acute care
hospitals to report inpatient data elements in a standardized manner. The
UHDDS data elements used in the DRG classification system are described
below. Proper DRG assignment and resulting reimbursement is dependent on
reporting these elements correctly.
o Diagnoses: All diagnoses that affect the current hospital stay are to be
reported.
Step C: Review Operative Reports, Special Procedure Reports, and/or Pathology Reports
forms. This operative set includes the operative report itself, the anesthesia
record, special consents for surgery, the recovery room record, and pathology
reports for specimen analysis.
o Note the results of special procedures such as cardiac catheterizations,
colonoscopies (lower endoscopies), esophagogastroduodenoscopies
(upper endoscopies), and bronchoscopies, with or without biopsies.
o Remember to sequence definitive before diagnostic procedure codes per
UHDDS rules.
o Note pathologic diagnoses given for any specimens removed at operation
that are usually dictated by the pathologist.
Step D: Review Physicians Progress Notes
Physicians orders are written or oral orders to nursing or ancillary personnel that
direct all treatments and medications to be given to the patient. Review the
doctors orders to determine the treatments given. Diagnosis codes establish the
medical necessity for servicesan important compliance issue as it is a law that
there must be documentation to back up every code submitted on claim forms.
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The discharge summary is a summary of the patients course in the hospital, the
patients condition on discharge, the discharge instructions, and the plan for
follow-up care. It includes all final diagnoses, as well as any significant principal
procedures and/or any other procedures.
o Review the DS for completeness and proper sequencing according to
UHDDS reporting rules. Physicians are often unfamiliar with coding
conventions and rules, so it is the coders responsibility to ensure that the
correct code assignment and sequencing are reported.
Make a list of any questions you have regarding unclear or missing information
necessary to code the encounter. Query the healthcare provider who generated
the notes. Never assume. Code only what you know from actual
documentation. If in doubt, query the physician, remembering if not documented,
not done. Without sufficient documentation, you cannot code, because
documentation is the basis of all coding.
Connect every procedure code to at least one diagnosis code for the same
encounter for document medical necessity.
Double check your codes by back coding. This means that you look up the code
you have assigned in the tabular list, re-read the code description, and then
compare it to the original notes to make sure these match. This will help catch
typos, accidentally missing a fourth or fifth digit, numbers transposed, etc.
Additional Tips
Review records coded previously! Pay attention to what is coded and what is
not coded; and how your codes differed.
Review the CPT Evaluation/Management Coding Guidelines and Resources
in the Course Resources section when assigning E/M codes.
If you think you are on the right track with a case but you just need clarification or
reassurance, send me a message or ask a fellow student using the coding forum
in the Discussion Board link. Just do not wait until the last day that the cases
are due because you might not get a response in time!
Types of Records
Format of Records
When coding these records, you are the physician office coder, which means you
are coding for the physicians office any treatment and evaluation/management
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that was done at that office during that visit and why these were done
(diagnoses) using ICD-9-CM or ICD-10-CM.
Do not code diagnoses that were not treated/addressed during the visit.
Follow ICD-9-CM and ICD-10-CM Diagnostic Coding and Reporting Guidelines
for Outpatient Services (Section IV).
Use E/M guidelines to determine appropriate E/M code.
Code procedures (services, testing, etc.) if these were done in the facility using
CPT/HCPCS codes.
When coding these records, you are the ambulatory surgery facility coder, which
means you are coding for the facility what procedure(s) were done, including
any preop testing, and why this procedure was done (diagnoses) using ICD-9CM or ICD-10-CM.
Do not code diagnoses that were not treated/addressed during the visit.
Follow ICD-9-CM and ICD-10-CM Diagnostic Coding and Reporting Guidelines
for Outpatient Services (Section IV).
Most of these cases are not going to have an E/M code unless it is a decision for
surgery case
Code procedures if these were done in the facility using CPT/HCPCS
codes. Do not forget your modifiers!
When coding these records, you are the emergency department coder, which
means you are coding for the department what treatment and
evaluation/management was done and why these were done (diagnoses) using
ICD-9-CM or ICD-10-CM.
For accidents, do not forget your E codes.
Do not code diagnoses that were not treated/addressed during the visit.
Follow ICD-9-CM and ICD-10-CM Diagnostic Coding and Reporting Guidelines
for Outpatient Services (Section IV).
Code procedures if these were done during the visit using CPT/HCPCS
codes.
Some treatments may be done more than once during a visit, do not forget to
code multiple procedures and do not forget your modifiers!
When coding these records, you are the outpatient services coder, which means
you are coding for the department or the facility the procedure(s) that were done
and why these procedure(s) were done (diagnoses) using ICD-9-CM or ICD-10CM.
Procedures include anything that can be coded from CPT/HCPCS, including
supplies, radiology, laboratory work, etc.
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Do not code diagnoses that were not treated/addressed during the visit.
Follow ICD-9-CM and ICD-10-CM Diagnostic Coding and Reporting Guidelines
for Outpatient Services (Section IV).
Code procedures using CPT/HCPCS codes.
Do not forget your modifiers!
Inpatient Records
Review the tutorial posted from Michelle Green about coding inpatient records.
When coding these records, you are the inpatient coder, which means you are
coding for the hospital in order to assign the DRG.
Follow ICD-9-CM and ICD-10-CM Guidelines for Selection of Principal Diagnosis,
Reporting Additional Diagnoses, and Present on Admission Reporting Guidelines
(Section II, Section III, and Appendix I).
For ICD-9-CM Procedure codes (Volume 3) and ICD-10-PCS codes, note:
o These are only used for coding procedures performed during an inpatient
hospitalization and any procedure that affects reimbursement should be
coded and reported.
o ICD-9-CM procedure codes and ICD-10-PCS are never to be used as
diagnostic codes.
o ICD-9-CM procedure codes and ICD-10-PCS are never to be coded on
outpatient/ambulatory records.
From the Buck Step-by-Step textbook, chapter 31, Inpatient Coding:
o In the inpatient setting, ICD-9-CM procedure codes (Volume 3) or ICD-10PCS are assigned instead of CPT or HCPCS codes. Procedure codes
need to be sequenced properly with the principal procedure as the firstlisted procedure. The principal procedure is one that is performed for
definitive treatment rather than for diagnostic or exploratory purposes, or
one necessary for a complication. If two procedures appear to meet this
definition, then the one most closely related to the principal diagnosis
should be assigned as the principal procedure. A procedure is considered
to be significant if it:
Is surgical in nature
Carries a procedural risk
Carries an anesthetic risk
Requires specialized training to perform
For a procedure to be significant it does not have to be performed
in the operating room. Many procedures are performed in the
emergency department, at a patients bedside, treatment room, or
in an interventional radiology department. Any procedure that
affects reimbursement should be coded and reported.
This means you are coding diagnoses treated/addressed during the
hospitalization and major procedures (only those that are significant and impact
the DRG) using ICD-9-CM/ICD-10-CM-PCS only for diagnostic and procedural
coding.
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Inpatient coders do not assign any CPT or HCPCS codes. The physician
billing department, who is separate from your department, will assign the
physician E/M codes to bill for any physician charges that are not covered by the
DRG reimbursement. Same with radiology, laboratory, therapy, etc.; these
departments will assign CPT/HCPCS and do their own billing.
Code
Code other diagnoses that coexist at the time of admission, that develop
subsequently, or that affect the treatment received and/or the length of stay.
These represent additional conditions that affect patient care in terms of requiring
clinical evaluation, therapeutic treatment, diagnostic procedures, extended length
of hospital stay, or increased nursing care and/or monitoring.
Code diagnoses that require active intervention during hospitalization. For
example: Admission for small-bowel ileus and subsequent aspiration pneumonia
that is treated with antibiotics and respiratory therapy. Code the ileus and
aspiration pneumonia.
Code diagnoses that require active management of chronic disease during
hospitalization, which is defined as a patient who is continued on chronic
management at time of hospitalization. For example: Admission for acute
exacerbation of COPD. The patient has depression that extends the stay and for
which psychiatric consultation is obtained. Code the COPD and depression. For
example: Admission for acute exacerbation of COPD. Physician lists "history of
depression" on face sheet, and the patient is given Desyrel. Code the COPD and
depression.
Code diagnoses of chronic systemic or generalized conditions that are not under
active management when a physician documents them in the record and that
may have a bearing on the management of the patient. For example: Admission
for breast mass; diagnosis is carcinoma. Patient is blind and requires increased
care. Code the breast carcinoma and blindness.
Code status post previous surgeries or conditions likely to recur that may have a
bearing on the management of the patient. For example: Admission for
pneumonia; status post cardiac bypass surgery. Code the pneumonia and status
post cardiac bypass surgery (V code or Z code).
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Code all procedures that fall within the code range 00.01 through 86.99, but do
not code 57.94 (Foley catheter).
Do not code status post previous surgeries or histories of conditions that have
no bearing on the management of the patient. For example: Admission for
pneumonia; status post hernia repair six months prior to admission. Code only
the pneumonia. But previous surgeries involving transplants, internal devices,
and prosthetics should be coded.
Do not code localized conditions that have no bearing on the management of
the patient. For example: Admission for hernia repair; the patient has a nevus on
his leg that is not treated or evaluated. Code only the hernia and its repair.
Do not code abnormal findings (laboratory, x-ray, pathologic, and other
diagnostic results) unless there is documentary evidence from the physician of
their clinical significance. For example: Admission for elective joint replacement
for degenerative joint disease. The laboratory report shows a serum sodium of
133; no further documentation addresses this laboratory result. Code only the
degenerative joint disease and the replacement surgery. For example: Admission
for elective joint replacement for degenerative joint disease. The laboratory report
shows a low potassium level, and the physician documents hypokalemia.
Intravenous potassium was administered by the physician for hypokalemia. Code
the degenerative joint disease, the replacement surgery, and hypokalemia.
Do not code symptoms and signs that are characteristic of a diagnosis. For
example: A patient has dyspnea due to COPD. Code only the COPD.
Do not code condition(s) in the Social History section that has no bearing on the
management of the patient.
Do not assign E codes, except those that identify the causative substance for an
adverse effect of a drug that is correctly prescribed and properly administered
and/or poisoning (E850-E949).
Do not assign Morphology codes (M codes).
Do not code procedures that fall within the code range 87.01 through 99.99. But
code procedures in the following ranges:
o 87.51-87.54 Cholangiograms
o 87.74 and 87.76 Retrogrades, urinary systems
o 88.40-88.58 Arteriography and angiography
o 92.21-92.29 Radiation therapy
o 94.24-94.27 Psychiatric therapy
o 94.61-94.69 Alcohol/drug detoxification and rehabilitation.
o 96.04 Insertion of endotracheal tube
o 96.56 Other lavage of bronchus and trachea
o 96.70-96.72 Mechanical ventilation
o 98.51-98.59 ESWL
o 99.25 Chemotherapy
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Medical Record #
Acct. #:
Name:
Admission Date:
Encounter Type:
Discharge Date:
Primary Payor:
Birthdate:
Sex:
Admission Type:
Length of Stay:
Discharge Disposition:
Admitting Physician:
Discharge MD:
Consultant:
CODE(S)
SHORT DESCRIPTION(S)
CODE(S)
SHORT DESCRIPTION(S)
Admit Diag
First-Listed Diag
OR
Princ Diag
Other Diag
Other Diag
Other Diag
Other Diag
Other Diag
Other Diag
Other Diag
Other Diag
Prin Proc
Other Proc
Other Proc
Other Proc
Other Proc
Other Proc
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