How To Do A Better Job With Hospital Coding

By Angel Dudley


It will be helpful for the person to learn more about hospital coding. Getting the notes about treatment and such organized is an important task that one will have to be serious and meticulous. It will surely become easier for the person to complete the said task when there are tips available for them to use.

For those coders who want to do a good job with the said task, they will have to follow several tips to ensure proper documentation. Regardless if one is an amateur or a professional, it is only natural for them to follow these tips. With the said tips, one can establish the rules for the documentation. Here are several of the tips that will set the rules for this task.

First, it is appropriate for people to document the weight, height, and blood pressure of the patient properly. By doing this, it will make it easier for the person to ensure a proper review for one's health history in the future. The documentation will show various changes with the patient's musculoskeletal system. It also shows what the said changes imply.

The codes that are to be used for the recording should be personally decided by the one in charge of the records. With this, it will not be easy for other people to contaminate one's records. They will not be downcoding or upcoding the said record. If it ever happens, it will result to skewed statistics and even loss of revenue. There is no one who will benefit from these results.

Some people might confuse referrals with consultations. Referrals mean that a transfer of care occurred. The referring physician is handing the problem to a new physician for further treatments. Consultation, on the other hand, means that the attending physician will provide evaluation and diagnosis of the patient's condition.

For every documentation, the coder should consider the modifiers one will have to use for it. This also means that the coder has to be familiar with the modifiers to avoid confusing one with the other. The modifiers have their own set up they describe. Determine what services the modifiers define.

There is the ABN too. This ABN, also known as advanced beneficiary notice, will be useful especially to Medicare patients. This is because the said notice will just signify that the patient agrees to provide payment for the medical care received when Medicare denies one's claims. The ABN lists the items that Medicare will pay for too.

An Incident To is very common in the medical field. This is especially used when the patients involved are Medicare policy holder. They will be used to signify that a non-physician practitioner is providing treatment for the patient. Of course, the presence of a professional physician is still requested even with the treatments of a non-physician practitioner.

Private payers are common in the medical field too. Dealing with the private payers is actually easier, since there is less hassle to it compared to those relying on insurance. With this, the private payers will make it possible to have non-physician practitioners deal with their condition. It should be cited in hospital coding properly too.




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