Medical Coding 1 Final Examination

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1. Differentiate between the official coding guidelines for using V codes in an inpatient and outpatient setting. The difference between the official coding guidelines for using V codes in an inpatient and outpatient setting is the guidelines for an outpatient setting indicates code sequencing for physician office and clinical encounters. V codes also may be used as the principal and secondary diagnosis in the inpatient setting compared to those that may be as the first listed or secondary diagnosis in the outpatient setting. The most important difference in the official guidelines of V codes is that the definition of principal diagnosis applies only to inpatients in acute, short-term, general hospitals. This means that the V coding guidelines for inconclusive diagnoses were developed for inpatient reporting and do not apply to an outpatient setting. Diagnoses are often not established at the time of the initial outpatient encounter or visit, because of this, it is an extremely important guideline when using V codes. In many outpatient cases, the diagnosis V code for a presenting sign or symptom must be assigned because a definitive diagnosis has not yet been determined.

2. You’ve started your first day at Venture Outpatient Surgery Center. Explain how you would code an operative report. To code an operative report the coder should first read through the entire report and take notes any possible diagnoses or abnormalities noted and any procedures performed. The coder should then review the physician’s list of diagnoses and procedures to see if they match. If the coder should locate a potential diagnosis or procedure not listed by the physician, they should bring this to the physician’s attention to see if it is significant enough to code. If preoperative and postoperative diagnoses are different, the coder should use the postoperative diagnosis. The coder should also review the pathology report if specimens were sent to pathology, to verify the diagnosis. If there is a discrepancy between the pathologist’s and the surgeon’s diagnoses, the matter should be discussed with the surgeon.

3. Discuss coding for obstetrics, including items covered by the global fee for antepartum and postpartum periods of normal pregnancy. Global coding for obstetrics is basically for the services and supplies needed for the antepartum, delivery, and postpartum period of a normal pregnancy. The antepartum period of pregnancy is the time of pregnancy from conception to the onset of delivery. The initial and subsequent history, all physical examinations, recording of blood pressure, weight, fetal heart tones, routine urinalysis, and monthly visits up to twenty-eight weeks gestation are included in antepartum care. After twenty-eight weeks, biweekly visits up to thirty-six weeks gestation, and weekly visits until delivery are also included in antepartum care. Delivery services included the hospital admission with history and physical, the management of uncomplicated labor, and the vaginal or cesarean delivery. Episiotomy and the use of forceps are also included for antepartum care. For postpartum care, normal, uncomplicated hospital and office visits for six weeks after either vaginal or cesarean section delivery are included.

1. Explain the importance of a fee schedule and the factors it’s based on. The importance of a fee schedule is to make sure that the physician is first setting their charges based on the physician’s skill, judgment, and time required to perform the service. The factors that a fee schedule is based on are the economic level of the community, the physician’s experience, the medical specialty of the practice, the charges of other physicians in the area, and the cost of the service or supply.

2. Why would a coder want to take special precaution when coding the diagnosis of human immunodeficiency virus or acquired immunodeficiency syndrome? When coding the diagnosis of HIV or AIDS, the coder should first...
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