1. 1 - 1 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. You Code It! A Case Studies Workbook 2 nd Edition By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 1 How To Abstract Notes

2. 1 - 2 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Introduction ·The most efficient and effective way to code an encounter between a health care professional and a patient is to review the physician’s notes for that encounter.

3. 1 - 3 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Steps To Coding 1.Read through notes completely 2.Highlight key words 3.List anything missing, incomplete, or confusing. Query the physician.

4. 1 - 4 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Steps To Coding 4.Code the diagnoses, signs, and/or symptoms as stated by the physician. 5.Code the procedures, services, and treatments provided at this visit. 6.Link every procedure code to at least one diagnosis code.

5. 1 - 5 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Steps To Coding 7.Double-check your work! Back code to ensure the code descriptions match what the physician wrote in the notes. Carefully check your data entry to ensure to no typos!

6. 1 - 6 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Medical Necessity ·Medical necessity is the assessment that the provider was acting according to standard practices in providing a procedure or service for an individual with a specific diagnosis.

7. 1 - 7 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Medical Necessity ·DIAGNOSIS codes explain ·WHY the physician provided treatment; ·WHY the patient needed the services; ·WHY the insurance carrier should pay for it all. ·Diagnosis codes EXPLAIN the medical necessity of the service.

8. 1 - 8 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Medical Necessity ·Diagnoses, signs, and symptoms are coded from ·ICD-9-CM volumes 1 and 2 NOTE: On October 1, 2013, this will be replaced with ICD-10-CM

9. 1 - 9 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Procedures ·Procedures, services, and treatments are coded from: ·CPT ·HCPCS Level II ·ICD-9-CM volume 3* *NOTE: On October 1, 2013, this will be replaced with ICD-10-PCS

10. 1 - 10 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Physician Notes ·SOAP notes ·Subjective Objective ·Assessment Plan ·Narrative notes ·Procedure notes/Operative notes

11. 1 - 11 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Interpreting Notes Read the complete documentation: Roseanne Tanner, a 23-year-old female, came to see Dr. Matlock with a complaint of arm pain. After a history and exam, he took an x- ray, and diagnosed her with a simple fracture of the ulna, right side. He applied a cast.

12. 1 - 12 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Interpreting Notes Identify key words: Roseanne Tanner, a 23-year-old female, came to see Dr. Matlock with a complaint of arm pain. After a history and exam, he took an x-ray, and diagnosed her with a simple fracture of the ulna, right side. He applied a cast. Diagnosis: WHY Procedures: WHAT

13. 1 - 13 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Interpreting Notes Missing information(?): Query the physician Diagnosis: Exactly what portion of the ulna bone was fractured? HOW and WHERE did she get her injuries (for the E-codes)?

14. 1 - 14 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Interpreting Notes Missing information(?): Query the physician. Procedures: Was the patient new or established? How many views of the arm x-ray were taken?

15. 1 - 15 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Interpreting Notes Find the diagnosis code or codes: Simple fracture of the ulna, shaft 813.22 Fall from ladder E881.0 At home E849.0

16. 1 - 16 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Interpreting Notes Find the procedure code or codes: Office visit, new patient, expanded problem focused 99202 X-ray, forearm, 2 views 73090 Closed treatment of ulnar shaft fracture; without manipulation 25530

17. 1 - 17 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Chapter Summary ·Use the following chapters to practice your coding skills for: ·Diagnosis coding ·Procedure coding ·DME, pharmaceutical, and other HCPCS level II coding ·All of the above!

18. 1 - 18 ©2011 by The McGraw-Hill Companies, Inc. All Rights Reserved. Please Note! The case studies in this chapter and this entire book are real patient records, written by various physicians and health care professionals around the country. Unlike many coding exercises, this documentation may not contain ALL of the details you need to determine the code…just like in real life. This is designed to help you begin your transition from classroom to career. Therefore, you may need to ‘query the physician’ [in class that would be your instructor]. You may need to research some procedures or determine inclusive signs and symptoms. All great rehearsal for your future!