Presentation on theme: "Coding for Medical Necessity"— Presentation transcript:
1Coding for Medical Necessity Chapter 10Codingfor Medical Necessity
2Coding for Medical Necessity The next step in learning to code correctly is to choose diagnoses and procedures/services from a case and link each procedure/service.
3Coding for Medical Necessity This chapter requires you to review case scenarios and patient reports to decide the right diagnoses and procedures/services to be coded, and medical necessity issues.
4Questions for Consideration Does this diagnosis or condition support a procedure or service provided during this encounter?Did the provider prescribe a new medication or change a prescription for a new or existing diagnosis or condition?
5Questions for Consideration Are positive diagnostic test results documented in the patient record to support a diagnosis or condition?Did the provider have to consider the impact of treatment for chronic conditions when treating a newly diagnosed condition?
6Coding and Billing Considerations You should also incorporate the following as part of practice managementCompletion of an Advance Beneficiary Notice (ABN) when appropriateImplementation of an auditing process
7Coding and Billing Considerations Review of local coverage determinationsComplete and timely patient record documentationUse of Outpatient Code Editor (OCE) Software
8Coding and Billing Considerations The following characteristics are associated with patient record documentation in all health care settings.Documentation should be generated at the time of service or shortly thereafter.
9Coding and Billing Considerations Delayed entries within a practical time frame (24 to 48 hours) are acceptable for purposes of clarification, corrections of errors, addition of information not initially available.
10Coding and Billing Considerations The patient record cannot be altered:Corrections or additions to the patient record must be dated, timed, and legibly signed or initialedPatient record entries must be legibleEntries should be dated, timed, and authenticated by the author
11Coding and Billing Considerations Medical practices and health care facilities should regularly participate in an auditing processAllows for review of patient records and CMS-1500 or UB-92 claims to evaluate coding accuracy and completeness of documentation
12Coding and Billing Considerations Local coverage determinations specify under what clinical circumstances a service is covered and correctly codedOCESoftware that edits outpatient claims submitted by hospitals, home health agencies, and other facilities
13Coding from Case Scenarios Case scenarios are a summary of medical dates from patients’ recordsIntroduces students to the process of abstracting diagnoses and procedures
14Coding from Case Scenarios Step 1Read case scenario and look up any words you don’t understandStep 2RereadHighlight diagnoses and symptomsThose that support medical necessity of the procedures performed
15Coding from Case Scenarios Step 3Code documented diagnoses, symptoms, procedures, signs, health status, and servicesStep 4Assign any modifiers that are appropriate
16Coding from Case Scenarios Step 5:Identify primary conditionStep 6:Link any procedure or services that were provided to the diagnosis to show medical necessity
17Coding from Patient Reports Services, diagnoses, and proceduresChosen and coded from the clinic notes, diagnostic reports, and the consultation reports
18Secondary PurposesPatient records do not relate directly to patient care, and they include:Evaluating quality of patient careProviding information to third-party payers for reimbursementProviding data for use in education, clinical research, and other uses
19Clinic NotesThere are two major formats that health care providers use for documenting clinic notes:Narrative clinic notesSOAP notesWritten in paragraph format
20SOAP Notes Written in outline format SOAP: Subjective Objective AssessmentPlan
21SOAP Notes Subjective Objective Part that contains the chief complaint Contains documentation of measurable observations made during the physical examination and diagnostic testing
22SOAP Notes Assessment Plan Contains diagnostic statement and may also include physician rationale behind diagnosisPlanStatement for physician’s plans for work-up and medical management of the case
23Operative ReportsNarrative of minor procedures that may have been performed in a physician’s office, to a more formal report by the surgeonRequired by hospitals and ambulatory surgical centers
24Information Contained in Outline Forms Date of surgeryPatient identificationPre- and postoperative diagnosis(es)List of the procedure(s) performedName of primary and secondary surgeons who performed surgery
25The Body of the Report Positioning and draping of patient for surgery Achievement of anesthesiaDetailed description of how the procedure(s) were performedIdentification of abnormalities found during the surgery
26The Body of the ReportDescription of how homeostasis was obtained and closure of surgical site(s)Condition of patient when they left the operating roomSignature of surgeon
27Procedure for Coding Operative Reports Step 1Make a copy of reportStep 2Carefully review all procedures performedStep 3Read body of report and make notes of procedures that need to be coded
28Procedure for Coding Operative Reports Step 4Identify main terms and subterms for procedures to be codedStep 5Underline and research any terms in the report that you cannot define
29Procedure for Coding Operative Reports Step 6Locate main terms in CPT/ indexStep 7Research all the suggested codes
30Procedure for Coding Operative Reports Step 8Return to index if you cannot find a code that matches the description of the procedures performedStep 9See if there are any modifiers that need to go on the procedures to explain it fully
31Procedure for Coding Operative Reports Step 10Code postoperative diagnosisStep 11Review code options with the physicianStep 12Assign final codes and any addendum the physician added to the original report
32Procedure for Coding Operative Reports Step 13List most significant procedure performed firstStep 14Be sure to destroy your copy of the report