Preview

Medical Coding and Billing

Satisfactory Essays
Open Document
Open Document
968 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Medical Coding and Billing
1. RADIOLOGY REPORT
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
IMPRESSION: Gallbladder ultrasound with limitations as discussed above. Grossly unremarkable sonographic appearance of the gallbladder. No obvious dilatation of the common duct. Large right pleural effusion identified.
What is the name of the physician that you are coding for? __________

2. RADIOLOGY REPORT
LOCATION: Hospital, Outpatient
PATIENT: Dan Diel
ORDERING PHYSICIAN: Daniel G. Olanka, MD
ATTENDING/ADMIT PHYSICIAN: Daniel G. Olanka, MD
RADIOLOGIST: Morton Monson, MD
PERSONAL PHYSICIAN: Ronald Green, MD
EXAMINATION: Gallbladder ultrasound.
CLINICAL SYMPTOMS: Increased bilirubin.
GALLBLADDER ULTRASOUND: Examination was technically difficult with some limitations due to overlying leads. Large right pleural effusion identified. Gallbladder is visualized. No obvious gallstones or gallbladder wall thickening. Only short portions of the common hepatic duct and common bile duct are visualized. Common hepatic duct measures 3.6 mm, and common bile duct measures 5.2 mm. These values are within normal limits. There is limited assessment of the liver, which is grossly unremarkable.
IMPRESSION: Gallbladder ultrasound with limitations as discussed

You May Also Find These Documents Helpful

  • Satisfactory Essays

    Hillcrest Case 7 H&P

    • 402 Words
    • 2 Pages

    PHSYICAL EXAMINATION: VITAL SIGNS: afebrile, BLOOD PRESSURE: 155/98. HEART RATE: 69. In general he is in no acute distress, alert and oriented X4. HEENT: Mucus membranes moist. No facial asymmetry. Left ear : WNL, Right ear: with profound hearing loss. LUNGS: clear to auscultation and percussion bilaterally. CV: Normal. S1, S2 without murmurs or rubs. GI: soft, non-tender, non-distended. No HSM. Positive Bowel sounds. GENITALIA: deferred. EXTREMEITIES: No edema. He has been admitted for left ankle surgery. NEUROLOGIC: intact with the exception on cranial nerve on the right.…

    • 402 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    * This is a very important step because it involves the determining of who is financially responsible for the visit. It also is used to establish what services may be covered under the type of insurance they have, along with payment options plan options if any, and what types may be available to the patient.…

    • 672 Words
    • 3 Pages
    Satisfactory Essays
  • Satisfactory Essays

    Case 3 Operative

    • 272 Words
    • 2 Pages

    INDICATIONS: Mr. Barua requires bronchoscopy because of recent-onset hemoptysis and a remote history of tuberculosis.…

    • 272 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    none

    • 2449 Words
    • 7 Pages

    The patient is a 21 year old male who presented with a history of sudden onset of abdominal pain, first generalized, and then localizing to the RLQ. The pain was accompanied with anorexia and nausea. It has become increasingly more severe over the past 3 hours so that the patient now cannot walk. He had one episode of vomiting, and has a low-grade fever of 100. On examination the patient…

    • 2449 Words
    • 7 Pages
    Satisfactory Essays
  • Satisfactory Essays

    case 2

    • 676 Words
    • 3 Pages

    HISTORY OF PRESENT ILLNESS: This 46-year-old gentleman with past medical history significant only for degenerative disease of the bilateral hips, secondary to arthritis. Present to the emergency room after having had three days of abdominal pain. It initially started three days ago and was a generalized vague abdominal complaint. Earlier this morning the pain localized and radiated down to the right lower quadrant he had some nausea and without emesis. He was able to tolerate p.o. earlier around 6 a.m., but he now denies having an appetite. Patient had a very small bowel movement this morning that was not normal for him, he has not passed gas this morning he's avoiding well. He denies fevers, chills or night sweats the pain is localized though the RLQ what out radiation at this point. He has never had a colonoscopy.…

    • 676 Words
    • 3 Pages
    Satisfactory Essays
  • Satisfactory Essays

    Step number four is the check out procedure. This takes place after the visit. The first thing is to record the medical codes for the visit. All procedures done in the office are coded correctly, dates are filled in, and the doctor makes sure that the diagnosis code is correct. The transaction codes are also entered, such as any payment made on that visit. Follow up visits are also scheduled at this time.…

    • 748 Words
    • 3 Pages
    Satisfactory Essays
  • Powerful Essays

    Medical Billing & Coding

    • 4989 Words
    • 20 Pages

    ICD-9-CM Coding Instructions: • Sequence the ICD-9-CM principal diagnosis in the first diagnosis position. • Assign all reportable secondary diagnosis codes including V codes and E codes (both cause of injury and place of occurrence). • Sequence the ICD-9-CM principal procedure code in the first procedure position. • Assign all reportable secondary ICD-9-CM procedure codes. ICD-10-CM and ICD-10-PCS Coding Instructions: • Sequence the ICD-10-CM principal diagnosis code in the first diagnosis position. • Assign all reportable secondary ICD-10-CM codes. • Sequence the principal ICD-10-PCS code in the first procedure position. • Assign all reportable secondary ICD-10-PCS codes. The scenarios are based on selected excerpts from health records. In practice, the coding professional should have access to and refer to the/entire health record. Health records are analyzed and codes assigned based on physician documentation. Documentation for coding purposes must be assigned based on medical record documentation. A physician may be queried when documentation is ambiguous, incomplete, or conflicting. The queried documentation must be a permanent part of the medical record. The objective of the cases and scenarios reproduced in this publication is to provide practice in assigning correct codes, not necessarily to emulate complete coding, which can be achieved only with the complete medical record. For example, the reader may be asked to assign codes based on only an operative report when in real practice, a coder has access to the entire medical record. The ICD-9-CM Official Guidelines for Coding and Reporting, published by the National Center for Health Statistics (NCHS), includes Present on Admission (POA) Reporting Guidelines in Appendix I. These guidelines supplement the official conventions and instructions provided within ICD-9-CM. Adherence to these guidelines when assigning ICD-9-CM diagnosis codes is required under the Health…

    • 4989 Words
    • 20 Pages
    Powerful Essays
  • Satisfactory Essays

    I. Introduction- begin with Thesis Statement: In one clear sentence state the focus of your paper. A. Key points (have at least three, but no more than five) 1. state each main point that you’ll be making in the paper 2. main point 3. main point 4. main point 5. main point Body of paper- outline the topic sentence and supporting research for each point you’ll be covering in the paper, beginning with point #1 stated in the introduction. A. Point 1- topic sentence idea 1. research concept a. supporting idea(s) b. connect to next concept 2. research concept a. supporting idea(s) b. connect to next concept 3. research concept a. supporting idea(s) b. connect to next topic idea B. Point 2- topic sentence idea 1. research concept a. supporting idea(s) b. connect to next concept 2. research concept CONTINUE FORMAT 3. “ “ C. Point 3- topic sentence idea and CONTINUE FORMAT D. Point 4- topic sentence idea and CONTINUE FORMAT E. Point 5- topic sentence idea and CONTINUE FORMAT 1. 2. 3. after last point is made and supported, create a transition to summary and conclusion Summary paragraph- create a key summary sentence that declares a wrap-up of concepts to begin this paragraph A. Follow the summary sentence with clear sentences that summarize each of the main ideas that have been discussed in the body of the paper 1. summary of point 1 2. summary of point 2 3. summary of point 3 4. summary of point 4 5. summary of point 5 Conclusion- transition to the ending of your paper and final thoughts in a paragraph Reference page in alphabetical order by last name (see APA format online and note examples from Reference section in back of textbook, and remember to cite all of your references in the body of your text following a summary concept or quote)…

    • 327 Words
    • 2 Pages
    Satisfactory Essays
  • Powerful Essays

    Outpatient coding is much less complicated than inpatient coding. First, outpatient coding is limited to a length of stay less than 24 hours whereas inpatient stays are longer due to the intensity of services. Second, for outpatient services, physicians are paid using CPT/HCPCS codes, whereas, hospitals are paid for their hospitality using a complex formula (MS-DRG) because of housing, feeding and nurturing the patient back to health. During an inpatient stay, the hospital charges based on the amount of time and effort spent on nursing a patient back to health so when it comes to normal birth vs an operation for an elderly person, the hospital will charge based on the severity of the patient’s illness.…

    • 1534 Words
    • 7 Pages
    Powerful Essays
  • Good Essays

    The compliance plans correlate with medical records documentation standards in which all staff members should follow billing rules. The documentation of a compliance plan consists of auditing areas of the coding and billing (medical records), providing ongoing training for all staff (continuing education), acquiring guidelines and procedures consistent, and to take action to correct any errors that may have occurred. For example all coding, within the medical record, must meet official guidelines. Not all codes are billable, but for every procedure, or documentation the patient has there must be a code listed. The documentation standards is the listings of procedures within a medical record stating which part of the bill is paid by the insurance plan and the part of the bill stating the patient’s bill. The relationship between the compliance plan and the medical record documentation standard would be to have everything found, and corrected before the physician signs the billing statement. If not done completely and accurately, both the staff member entering this information and the physician could be negligent and charged with fraudulent behavior.…

    • 258 Words
    • 2 Pages
    Good Essays
  • Satisfactory Essays

    5. In an acute care hospital, when is it appropriate to assign a code such as 794.31—nonspecific abnormal electrocardiogram? It’s never appropriate to assign codes of this type for an acute care setting.…

    • 346 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    Medical Transcription

    • 659 Words
    • 3 Pages

    PAST SURGICAL HISTORY: Pilonidal cyst, removed in the remote past. Had plastic surgery on her ears as a child.…

    • 659 Words
    • 3 Pages
    Satisfactory Essays
  • Good Essays

    understanding of medical billing and coding and what is has to offer if you wanted to…

    • 874 Words
    • 4 Pages
    Good Essays
  • Satisfactory Essays

    Medical Surgical Nursing

    • 695 Words
    • 3 Pages

    1. What first actions should the nurse take after the patient has arrived in the emergency department?…

    • 695 Words
    • 3 Pages
    Satisfactory Essays
  • Good Essays

    T.B. is a 65-year-old retiree who is admitted to your unit from the emergency department (ED). On arrival you note that he is trembling and nearly doubled over with severe abdominal pain. T.B. indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid-back as a deep, sharp boring pain. He is more comfortable walking or sitting bent forward rather than lying flat in bed. He admits to having had several similar bouts of abdominal pain in the last month, but “none as bad as this.” He feels nauseated but has not vomited, although he did vomit a week ago with a similar episode. T.B. experienced an acute onset of pain after eating fish and chips at a fast-food restaurant earlier today. He is not happy to be in the hospital and is grumpy that his…

    • 1681 Words
    • 7 Pages
    Good Essays