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Office vists: Examination and coding


Preformatted files that serve as a starting point

What method of documentation is considered efficient



Process of recording spoken words into a phone or other recording device to be transcribed into written form

Digital dictation

The process of using a microphone, a headset connected to a computer, a smart phone or a Personal digital assistant

Voice recognition software

Software that recognized spoken words
(enables dictation to be possable)

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


A list of a plan's selected drugs and their proper dosages

If the medication is not in formulary what will EHR do?

Can suggest an alternative drug

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

Orders refers to...

ordering lab teasts, radiology procedures and pathology procedures

Electronic Order entry provides

Numerous safty and cost control benefits

Ordering electronically allows

Physicians to process orders and receive results nore rapidly

Medical coding

applying HIPAA mandated code sets to assign codes to diagnoses and procedures

3 required Code Sets:



Current Procedural Terminology


Healthcare common procedures coding system


International classification of diseases-9th revision-clinincal modification


Replacing ICD-9-CM mandated to be used beginning in 2013

When is ICD-10-CM replacing ICD-9-CM?

Beginning of 2013

ICD-9-CM codes are

3,4 or 5 digits

ICD-10-CM codes will be

5,6,7 digits

If a service is not documented it is not

going to be paid

Incomplete or incorrect records can cause

Denied claims or possibly investigation into a fraudulent activity

Primary Diagnosis

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


Current Procedural Terminology


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

E/M Codes

Cover physicians' services performed to determine the optimum course for patient care


Assigning a higher level code than is supported by documentation

What may be considered fraud


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

NEVER________from the ____


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

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