timing. Often‚ diagnoses are not established at the time of the initial encounter in the outpatient setting and it may take two or more visits prior to a confirmed diagnosis. The documentation to support the reason for the visit should describe the patient’s condition‚ using terminology that includes either specific diagnoses and/or symptoms‚ problems‚ or reasons for the encounter. In the instance where a discrepancy is discovered‚ determining the first-listed diagnosis per the coding conventions of
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LOCATION: Outpatient‚ Hospital PATIENT: Stan Hope SURGEON: Mohamad Almaz‚ MD PREOPERATIVE DIAGNOSIS: Left shoulder pain and numbness‚ past shoulder injury POSTOPERATIVE DIAGNOSIS: Normal shoulder PROCEDURE PERFORMED: Diagnostic arthroscopy‚ left shoulder CLINICAL HISTORY: This is a 57-year-old with a l0-year-old rotator cuff tear injury to his left shoulder. The patient does heavy lifting for a living. For the past 6 months the patient has been experiencing pain in this shoulder with
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------------------------------------------------- Purpose of Coding ------------------------------------------------- Purpose of Coding ICD-10-CM implementation date is set for October 1‚ 2014. ICD-10-CM implementation date is set for October 1‚ 2014. ICD-9-CM versus ICD-10-CM ICD-9-CM versus ICD-10-CM Purpose of coding Purpose of coding ICD-9 | ICD-10 | 3-7 characters in length | 3-7 characters in length | 13‚000 codes | 68‚000 codes | First digit can be alpha or numeric
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Healthcare Common Procedure Coding System (HCPCS) is divided into two distinct subgroups: Level I and Level II HCPCs. Level I is made up of the Current Procedural Terminology Category (CPT)codes. CPT codes are used to bill public or private insurances programs for medical services and procedures. Level II HCPCS is the standard of coding used to identify products‚ supplies‚ and services not included in the CPT. These include transportation services‚ durable medical equipment (DME)‚ prosthetics‚ orthotics
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The coding of DM can be difficult Learn to look for: Various manifestations Types—type 1 or type 2 Controlled or uncontrolled Default is type 2 DM if Type of diabetes mellitus not documented Use Z code for long-term use of insulin--Z79.4 Do not use Z code if insulin is temporarily given to control blood sugar In ICD-10-CM there are 5 category codes for diabetes mellitus: E08 Diabetes mellitus due to underlying condition (code underlying condition first) E09 Drug or chemical induced
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1. Decrease Medicare Expenditures and Re-Distribute Physicians payments more equitibly are two of the three goals of Physician Payment Reform. The third goal of the Physicians Payment Reform is to Ensure quality healthcare at a responsible rate. 2. Mr. Jones was admitted to the hospital for severe hip pain. During the ortho surgeon’s initial visit‚ it was determined that Mr. Jone’s had a fractured hip and stated a required surgical intervention. The modifier that would be used for the hospital visit
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The Healthcare Common Procedure Coding System (HCPCS) are codes that are for reporting professional services‚ procedures and supplies. Included in that is medical equipment ‚ ambulance services‚ orthotics‚ supplies‚ medication and dental procedures. The HCPCS was developed by the Health Care Financing Administration in 1983. As of 2001 the HCFA is now Centers for Medicare and Medicaid Services (CMS). HCPCS is divided into two subsystems‚ Level I and Level II. Level I is CPT (Current Procedural
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in a medical assistant’s decisions on a daily basis. The research includes three different situations where the medical assistant was influenced by laws and regulations and the release of patients personal and medical information. I will also be discussing the relevant components of a patient’s medical record‚ and what a physician looks for in it. There will be an overview of all the documentation that would be in these components. The first situation where the actions of a medical assistant
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Medical Profession Responsibilities Medical Profession Responsibilities This paper will discuss the federal law that governs Protected Health Information (PHI) and the elements of compliance that must be met. This paper will also describe two examples of improper privacy disclosure and some challenges a medical office might have maintaining strict confidentiality. The federal law that governs Protected Health Information (PHI) is the Health Insurance Portability and Accountability Act (HIPAA)
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on our culture. The development in technology is driven by those who have a passion for delving deep into the underlying mechanics to unravel mysteries of the technology and to further develop it for both their own needs and the needs of others. “Coding Freedom” by E. Gabriella Coleman explores and analyzes a new culture that has developed amongst these passionate individuals‚ known as hackers‚ who have helped advance new technology in recent years. Coleman first attempts to provide a solid background
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