UP.01.01.01 requires the organization to conduct a pre-procedure verification process prior to the start of any procedure. The hospital meets this standard by following its policy titled “Site Identification and Verification (Universal Protocol)” which describes the process that is used prior to the start of any operative or invasive procedure. The hospital’s use of the “Pre-Procedure Hand-Off” checklist provides the documentation required to demonstrate compliance with the standard. Because of the criticality of this standard, I recommend a focused medical record review to measure compliance with the use of the pre-procedure checklist. If the audit reveals the checklist is completed consistently, full compliance with the standard will be verified and no further action will be required.…
There are three different code categories, Category I, II, and III. The first category I codes are the most numerous and each are five digits long all numeric. Each of them has a description of the procedure the code is for. For example 99204 is Officer or other outpatient visit for evaluation and management of a new patient. They are grouped into sections, but they can be used by any physician. For instance a regular physician may use a surgical code even though he is not a surgeon. Each of these codes are for procedures that are known working procedures. So chemotherapy is a known working procedure it would fall under category I, but a procedure that they are still testing for effectiveness would not be in this category. Category II codes are used to track performance measures for medical goes. For instance, when a patient comes in to lose weight or to quit smoking, then the category II code comes into use. Each of these codes has an alphabetic character as the last digit. Category III codes are used for temporary technology, services, and procedures, but if they are proven effective then it can turn into a permanent code. So these codes are only used for experimental procedures. When a new procedure is introduced, but not yet proven effective then it is assigned a temporary code. If the procedure is proven affective then it can switch and become a permanent code, and these also have an alphabetic character for the last digit. So an easy way to remember these categories would be:…
Most of the codes we see in the United States today are version 9, called ICD-9-CM codes. With few exceptions, the paperwork we receive when we leave a doctor’s office will contain both CPT codes (Current Procedural Terminology) to describe the service that was rendered for billing purposes, and ICD-9-CM codes to describe why that service was provided. Further, most death certificates filed since, 1977 will have an ICD-9 code on them.…
| IM 02.02.01 element 2The hospital uses standardized terminology definitions, abbreviations, acronyms, symbols, and dose designations. The hospital follows its list of prohibited abbreviations, acronyms, symbols and dose designations.…
Balasa, D. A. (2012, March 2). Archived Public Affairs Articles :: AAMA - The American Association of Medical Assistants. Retrieved April 2012, from http://www.aama-ntl.org/CMAToday/archives/publicaffairs/details.aspx?ArticleID=886…
The CPT codes have three categories, starting with Category I, then Category II, and Category III. There are key words associated with these three code categories which include “common,” “optional,” and “temporary,” these key words help to make the coding process easier for employees to understand. Common codes are referred to when using Category I codes, because this category of codes is the most widely used throughout any medical practice. Category II codes are optional codes and Category III codes are known as temporary codes.…
In 2001, The Joint Commission issued a Sentinel Event Alert on the subject of medical abbreviations, and just one year later, it’s Board of Commissions approved a National Patient Safety Goal requiring accredited organizations to develop and implement a lost of abbreviations not to use. In 2004, the joint Commission created its “do not use” list of abbreviations as part of the requirements for meeting that goal.…
The medical coding process can be very difficult to understand. Today, I will do my best to try and explain it as simply as possible. It is my goal to make you, the employees, understand this process better so that your job becomes easier to complete.…
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…
with the goal of developing their members as a leader in collaboration and a catalyst for…
Following retirement, the average elderly American is sustaining themselves on the equivalent of minimum wage or funds from Social Security. Chronic disease is an ongoing pandemic across the world, but as we have seen the cost of medication has been at an all-time high. It is reported that the average elderly adult spends a minimum of 23% of their income on medication alone (Sagon, 2015). Of course, these statistics will vary since America is such a diverse population.…
ANA provides you significant advantages joining this professional nursing organization. Advantages of joining the organization varies in range from meeting various people from your own profession, keeping up to date knowledge with growing improvement in the field, gaining leadership skills, etc.…
Some of the key points from this letter is that the American Nurse Association (ANA) is not in favor of the American Health Care Act (AHCA) because the act deliberately threatens health care affordability, access, and delivery for individuals across the nation (Cipriano, 2017).…
Acceptable abbreviations have been studies by a few organizations. JCAHO (Joint Commission on Accreditation of Healthcare Organizations) provides institutions with a list of dangerous abbreviations that should be avoided in clinical documentation. Also, ISMP (Institute for Safe Medication Practice) promotes the consistent application of not using specified abbreviations to prevent errors. The policy recommends not using abbreviations, symbols and acronyms in medical communication. According to ISMP, abbreviations should never be used in "internal external communication, telephone/verbal prescriptions, computer generated labels, labels for drug storage bins, medication administration records, as well as pharmacy and prescriber computer order entry screens." With the use of these policies…
In addition, the CDC also lists other resources that can be utilized to prevent and help educate about ACEs. One thing that was mentioned was, VetoViolence, which is a website that acts as a source for trainings, tools, and resources for violence prevention professionals (CDC 2016). Its interactive tools and trainings are designed to help practitioners stop violence before it begins, which may address gaps between practitioners knowledge regarding ACEs. In addition, case studies have also been done in Washington and Oklahoma where ACE data has been used in helping to prevent child abuse and neglect. Oklahoma has strategically applied for, received, and disseminated federal funding to address childhood adversity specifically (CDC 2016). These…