Quiz 15: Coding Muscular and Skeletal Conditions

Medicine

The interpretation of physician's observations and diagnosis in a simple form is known as coding. To provide accurate code it is important to understand the physician's notes and look for precise information. To ensure accurate coding, the communication between the coding specialist and the health care provide should be clear and complete. Abstracting physician's code refers to choosing keywords from the notes depicting the need for treatment. Three basic steps are followed for abstracting the physician's notes. The steps are as follows: • Determining the reason for treatment and coding. • Assigning more than one code to explain the complete diagnosis and treatment plan. • Analyzing the diagnostic statement. It is crucial to read the physician's notes thoroughly to understand what were the symptoms experienced by the patient as well as the diagnosis made by the physician. If the physician has attended to multiple complaints then it is important to note the primary diagnosis. Sometimes, there might be preoperative and postoperative notes with different findings, in such cases postoperative findings should be considered for coding. The physician's notes might have some keywords indicating the confirmed diagnosis. Thus, it is important to assign multiple codes for multiple diagnoses if required. After discovering all the relevant information from the notes separate the diagnostic statement and find out the word or words spotting the disease. The keywords selected must depict the reason for providing treatment to the patient. For example, if the keyword is "pulmonary necrosis" then it depicts the condition of "necrosis" meaning dead "pulmonary" tissues. The appropriate code must be selected according to the findings. Therefore, abstracting the information in the form of keywords from the physician's notes is the primary job of every coding specialist. These keywords help in determining the chief complaints of the patients, diagnosis by the physician and treatment provided. The specific information derived from these details helps in assigning the accurate codes.

Healthcare provider is responsible for diagnosing the disease based on signs and symptoms. A healthcare professional provides the care and treatment to the patient with a valid reason. Healthcare professionals are always ready and enthusiastic to help and support their patients. The patient may come to the healthcare professional due to the following reasons: • When the patient feels symptoms of any disease. • The patient may come to the healthcare professional for a routine checkup. • When the patient gets a sudden stroke or suffered from any trauma. • The patient may come to healthcare professional for evaluation of blood test report. Thus, in any health-related problem, the patient may come to a healthcare professional.

Medical necessity is a term which is used to justify the treatment and procedures performed on any individual by health care professionals. It depends on the diagnosis made by the physician. Coding is a form of representation of diagnosis in order to make sure that the message interpreted is understandable for everyone related to health and well being of a population. Coding needs to be done in order and with accuracy. Following are the seven steps to be considered for coding any diagnosis: • Go through the physician's notes and superbill. It is better to create a copy of all the documents for any markings. • Abstract physician's notes in order to derive keywords and to differentiate correctly between diagnosis and procedures. • Catalogue all the queries regarding any missing or unclear information which seems to be relevant for coding and consult the health care provider. • Provide code for suitable signs and symptoms if the clear diagnosis is not present or else code for the diagnosis with a description stating the reason for treatment given to the patient by the health care provider. Use the most precise codes on the basis of the documents available. • Provide codes covering the diagnosis with maximum details with relation to the treatment and procedures provided. • It is appropriate to code only for those diseases which require treatment in the current visit. • To provide a detailed view, one should assign as many codes as required. • Assign codes for every procedure mentioned in the notes unfolding the treatment given by the service provider. • For verification of medical necessity, linking of every procedure code to diagnosis code is important and needs to be done accurately. • Codes should be double checked by referring to the books and code descriptions provided. Therefore, following the guidelines will help in assigning precise and correct codes. The accuracy of codes helps the patient and the insurance provider to understand the diagnosis and reason for treatment provided.