Billing, Coding, & Documentation (not done) Flashcards
what provides a comprehensive historical vehicle promoting excellence in care delivery to a patient, transcending communication barriers, and facilitating care coordination among multiple disparate providers and facilities.
medical record
what does the medical record serve as?
the basis for a variety of financial, legal, and administrative functions including:
- the documentation for both professional and facility fee reimbursement
- quality and safety assessments
- malpractice litigation and disability determinations
- community-based care and public health initiatives.
what systems are designed to replace paper-based ordering systems.
Computerized provider order entry (CPOE) systems
Types of Unintended Consequences of Computerized Provider Order Entry Systems
- More or new work for clinicians
- Unfavorable workflow issues
- Never-ending system demands
- Problems related to persistence of paper orders
- Unfavorable changes in communication patterns and practices
- Negative feelings toward the new technology
- Generation of new types of errors
- Unexpected changes in an institution’s power structure, organizational culture, or professional roles
- Overdependence on the technology
these types of notes, whether formatted as preprinted paper progress notes with check boxes or electronically constructed as combinations of macros and click-boxes, are common, appropriate documentation tools, which enhance legibility and facilitate efficient documentation.
templated notes
Electronic notes often become the source for increasingly prevalent “cut-and-paste” errors, how can we prevent this?
- Make each note specific to the patient on that encounter date.
- Modify information and language brought forward from any previous encounters so the current documentation demonstrates the distinct clinical service of today.
- Do not include excessive data or repetitious information that is not relevant to the current service
Pays hospitals for inpatient services using an inpatient prospective payment system (IPPS), which relies on the dx in order to group services delivered to an inpatient into a ____ severity-adjusted diagnosis related group (MS-DRG).
Medicare
Provider services are MC reported using what type of payment _____
* Lists descriptive terms and identifying codes to report medical services and procedures.
* ____ provides a uniform language to accurately describe all medical, surgical, and diagnostic services and procedures.
- American Medical Association (AMA) Current Procedural Terminology (CPT)
- CPT
Selection of an Evaluation and Management level (E/M) focuses upon the content of three key components:
History, PE, and Medical Decision Making
what is the 4th key component of Evaluation and Management level (E/M)
Time
but only affects the E/M level when counseling and/or coordination of care dominate more than 50% of the physician’s total visit time
The elements of history include these 4 components
- the chief complaint (CC)
- history of present illness (HPI)
- review of systems (ROS)
- past, family, and social histories (PFSHs)
These do not have to be in separate, bulleted segments, but can all be included in a narrative format.
Typically, the reason for the visit is often quoted from the patient’s own words as a sign or symptom, such as, “my belly hurts.”
CC
Always document a CC in the progress note, even absent an acute complaint, such as, “pneumonia follow-up.”
Conveys information about the CC, from either the origin or the interval between sequential patient encounters.
HPI
8 elements of the HPI
location, quality, severity, duration, timing, context, modifying factors, and associated signs/symptoms.
The HPI is then quantified as ___ (one to three elements) or ____ (four or more elements).
brief
extended
