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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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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!