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The Complete Diagnosis Coding Book 2nd Edition by Shelley Safian
Edition 2ISBN: 978-0073374512The Complete Diagnosis Coding Book 2nd Edition by Shelley Safian
Edition 2ISBN: 978-0073374512 Exercise 2
Apply correctly the appropriate steps to coding.
Explanation
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The healthcare diagnoses, procedures, medical services, and equipment are transformed into alphanumeric codes in medical coding. The information is abstracted from the physician's notes, lab reports, superbills, and other related documents. Appropriate codes are assigned to the information for insurance claims.
Accurate coding is a seven-step process that is followed to code a health care encounter in an appropriate manner. The appropriate steps of coding can be explained as follows:
• First, the superbill and the physician's notes are read completely.
• The physician's notes are read again, and the keywords regarding diagnoses and procedures are highlighted. The key words are then evaluated, and the diagnostic and procedural statements are distinguished.
• A list of questions regarding the missing or unclear information is made. The queries are cleared with the help of a health care provider. Information available in the actual documentation is only used for coding purposes.
• Each diagnosis and appropriate signs or symptoms are coded. The most accurate codes are based on the documentation.
• Each procedure that is stated in the notes is coded. The codes can be reviewed in the book, titled "The Complete Procedure Coding Book".
• Every medical procedure is linked to coding. At least one diagnosis code is used to verify the medical condition of a patient.
• The codes are again checked from the books and notes, and then the code descriptions are assigned.
The appropriate coding requires seven steps. Coding involves gathering information by reviewing the physician's notes, lab reports, superbill form, and other necessary documents for the encounter. Diagnoses, symptoms, and procedures are accurately coded based on the documentation. The codes are re-checked before submission.
Accurate coding is a seven-step process that is followed to code a health care encounter in an appropriate manner. The appropriate steps of coding can be explained as follows:
• First, the superbill and the physician's notes are read completely.
• The physician's notes are read again, and the keywords regarding diagnoses and procedures are highlighted. The key words are then evaluated, and the diagnostic and procedural statements are distinguished.
• A list of questions regarding the missing or unclear information is made. The queries are cleared with the help of a health care provider. Information available in the actual documentation is only used for coding purposes.
• Each diagnosis and appropriate signs or symptoms are coded. The most accurate codes are based on the documentation.
• Each procedure that is stated in the notes is coded. The codes can be reviewed in the book, titled "The Complete Procedure Coding Book".
• Every medical procedure is linked to coding. At least one diagnosis code is used to verify the medical condition of a patient.
• The codes are again checked from the books and notes, and then the code descriptions are assigned.
The appropriate coding requires seven steps. Coding involves gathering information by reviewing the physician's notes, lab reports, superbill form, and other necessary documents for the encounter. Diagnoses, symptoms, and procedures are accurately coded based on the documentation. The codes are re-checked before submission.
The Complete Diagnosis Coding Book 2nd Edition by Shelley Safian
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