How To Handle Hospital Coding Properly

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 of all, it is only appropriate to document blood pressure, weight, and height. By doing this, the person can review a portion of one's health history. It will also become easier for the person to see what the changes in one's musculoskeletal system and blood pressure are. Of course, it also allows the person to determine what these changes signify.

It is also necessary for the person to decide on the codes to be used personally. This is so that the person can avoid having other people downcode or upcode the kind of E&M visits that one has given. If this ever happens, this will just result to either a lost in revenue or a skewed statistics for the higher-level visits.

Confusing referrals with consultations should be avoided as well. This is because referrals are meant to mark a transfer of care. A referring physician hands over the patient to a new physician to further the treatment. Consultation refers to an attending physician providing proper diagnosis and assessment of a 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.

An ABN or advanced beneficiary notice might be useful. That is why it is recommended to get this from a Medicare patient. The ABN will typically contain the list of the items that the said insurance policy will and will not pay for. Signing this ABN means that the patient agrees to paying for the entire bill when the insurance policy denies the claim.

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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