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Process of recording spoken words into a phone or other recording device to be transcribed into written form
The process of using a microphone, a headset connected to a computer, a smart phone or a Personal digital assistant
EHR safety checks (e-prescribing)
* Drug allergys
* Drug to drug interactions
*Potentail conflicts using information in the patient's record.
Drug to diagnosis warning
Alerts physician to potential problems with a planned medication based on the patient's illness
What is the advantage of e-prescribing?
Patient will not have to typically wait to pick up a prescription once they arrives at the pharmacy
Incomplete or incorrect records can cause
Denied claims or possibly investigation into a fraudulent activity
The diagnosis that relates to the patients stated reason for the visist (Chief Complaint)
Steps to Assign Diagnosis Code
* Review complete medical documentation
* Abstract the medical conditions from the visits documentation
*Identify the main term for each condition
* Locate the main terms in the Alphabetic index
*veryify the code in the Tabular List
Healthcare Common Procedure Coding System
(for things used in medical practices but not listed in CPT- such as supplies and equipment)
What are the three levels of CPT codes
1. Category codes- 5 digits( no decimals) plus a desciptor
2. Category 11 Codes- Used to track performance measures for a medical goal, such as reducing tobacco use
3. Category 111 codes- Temporary codes for emerging technology, services an d procdures
What are the six sections of category 1 procedure codes?
Evaluation and managment
Pathology and laboratory
Procedure Code Assignment Steps
* review complete medical documentation
* Abstract the medical procedures from the vist documentation
*Identify the main term for each procedure
* Locate the main terms in the CPT index
* Verify the code in the CPT main text
* Determine the need for modifiers
E/M Code selection process
1- Determine category and subcategory of service based on place of service and patient status
2- Determine the extent of the history that is documented
3-Determine Extent of exam documented
4- Determine the complexity of medical decision making documented
5- analyze requirements to report the service level
6 Verify service level based on Nature of problem, Time, counseling and care coordination
7- Verify Complete Documentation
ASSIGN THE CODE!
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