Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician's notes, laboratory and radiologic results, etc. Medical coding professionals help ensure the codes are applied correctly during the medical billing process, which includes abstracting the information from documentation, assigning the appropriate codes, and creating a claim to be paid by insurance carriers.
The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
To indicate that service or procedure that has been performed and has been altered by some specific circumstance but not changed in its definition or code.
25 (Hospital and Physician Coding) and 27 (Hospital Coding)
When two surgeons work together as primary surgeons performing distinct part of a procedure, each surgeon should report his distinct operative work by adding 62 modifiers.
Cerumen impaction is a condition in which earwax has become tightly packed in the external ear canal to the point that the canal is blocked.
3 R’S are Request (By appropriate source like Physician or third party but not by patient’s request), Render (Providing service by consultant) and Report (The results of consultation have to be given).
DRG is a system to classify hospital cases into one of the originally 747 groups. These are based on ICD diagnoses, procedures, age, sex, discharge status, and the presence of CC-complications or co morbidities &MCC-Major complication and co morbidity.
Simple Repair: Involving primarily epidermis or dermis, or subcutaneous tissue without significant involvement of deeper structures and requires one layer closure.
Intermediate Repair: Require one or more of the deeper layers of the subcutaneous tissue and superficial fascia and heavily contaminated forthis requiring extensive cleaning.
Complex Repair: For this require more than layered closure Ex: scar revision, debridement.
One layer closure is simple repair. Two layers of more is intermediate repair. Up to muscle closure complex repair example debridement, scar revision.
Surgical removal of lesion means any abnormal skin condition.
Fracture reduced without incision is Closed Reduction and the one that is reduced with an incision is Open Reduction
Yes- It is treated with open reduction with internal fixation (ORIF)
Differs body system to system and main guidelines are anesthesia and fluoroscopic guidance observed or done
70000 series mainly having two components like professional and Technical component. Any procedure which involves images called as radiology coding. Modifiers are 26, TC, 50, RT, LT, 59.
7 Components are History, Examination, MDM-Medical Decision Making, Counseling, Coordination of care, Nature of presenting problem and Time. The 3 basic key components are HX, Exam and MDM