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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
You Code It!A Case Studies
Workbook2nd Edition
By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA
Chapter 1Chapter 1
How To Abstract NotesHow To Abstract Notes
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Introduction
· The most efficient and effective way
to code an encounter between a health
care professional and a patient is to
review the physician’s notes for that
encounter.
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Steps To Coding
1. Read through notes completely
2. Highlight key words
3. List anything missing, incomplete,
or confusing. Query the physician.
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Steps To Coding
4. Code the diagnoses, signs, and/or
symptoms as stated by the physician.
5. Code the procedures, services, and
treatments provided at this visit.
6. Link every procedure code to at least
one diagnosis code.
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Steps To Coding
7. Double-check your work! Back code
to ensure the code descriptions match
what the physician wrote in the notes.
Carefully check your data entry to
ensure to no typos!
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Medical Necessity
· Medical necessity is the assessment
that the provider was acting according
to standard practices in providing a
procedure or service for an individual
with a specific diagnosis.
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Medical Necessity
· DIAGNOSIS codes explain
· WHY the physician provided treatment;
· WHY the patient needed the services;
· WHY the insurance carrier should pay for
it all.
· Diagnosis codes EXPLAIN the medical
necessity of the service.
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Medical Necessity
· Diagnoses, signs, and symptoms are
coded from
· ICD-9-CM volumes 1 and 2
NOTE: On October 1, 2013, this will be replaced with ICD-10-CM
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Procedures
· Procedures, services, and treatments
are coded from:
· CPT
· HCPCS Level II
· ICD-9-CM volume 3*
*NOTE: On October 1, 2013, this will be replaced with ICD-10-PCS
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Physician Notes
· SOAP notes
· Subjective • Objective
· Assessment • Plan
· Narrative notes
· Procedure notes/Operative notes
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Interpreting Notes
Read the complete documentation:
Roseanne Tanner, a 23-year-old female, came to
see Dr. Matlock with a complaint of arm
pain. After a history and exam, he took an x-
ray, and diagnosed her with a simple fracture
of the ulna, right side. He applied a cast.
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Interpreting Notes
Identify key words:
Roseanne Tanner, a 23-year-old female, came to
see Dr. Matlock with a complaint of arm
pain. After a history and exam, he took an
x-ray, and diagnosed her with a simple
fracture of the ulna, right side. He applied
a cast.
Diagnosis: WHY
Procedures: WHAT
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Interpreting Notes
Missing information(?): Query the physician
Diagnosis:
Exactly what portion of the ulna bone was
fractured?
HOW and WHERE did she get her injuries
(for the E-codes)?
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Interpreting Notes
Missing information(?): Query the physician.
Procedures:
Was the patient new or established?
How many views of the arm x-ray were
taken?
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Interpreting Notes
Find the diagnosis code or codes:
Simple fracture of the ulna, shaft 813.22
Fall from ladder E881.0
At home E849.0
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Interpreting Notes
Find the procedure code or codes:
Office visit, new patient, expanded
problem focused 99202
X-ray, forearm, 2 views 73090
Closed treatment of ulnar shaft fracture;
without manipulation 25530
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Chapter Summary
· Use the following chapters to practice
your coding skills for:
· Diagnosis coding
· Procedure coding
· DME, pharmaceutical, and other
HCPCS level II coding
· All of the above!
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©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved.
Please Note!
The case studies in this chapter and this entire book are real
patient records, written by various physicians and health care
professionals around the country. Unlike many coding
exercises, this documentation may not contain ALL of the
details you need to determine the code…just like in real life.
This is designed to help you begin your transition from
classroom to career. Therefore, you may need to ‘query the
physician’ [in class that would be your instructor]. You may
need to research some procedures or determine inclusive
signs and symptoms. All great rehearsal for your future!