What Is Medical Coding? What Is Medical Coding? Medical Coding Professionals Provide a Key Step in the Medical Billing Process
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NUTRITIONAL COUNSELING Corporate Medical Policy
NUTRITIONAL COUNSELING Corporate Medical Policy File Name: Nutritional Counseling File Code: RB.NC.01 Origination: 04/2002 Last Review: 07/2019 Next Review: 07/2020 Effective Date 04/01/2020 Description/Summary Nutritional counseling is individualized advice and guidance given to members at nutritional risk due to nutritional history, current dietary intake, medication use or chronic illness, about options and methods for improving nutritional status. A certified, registered, or licensed healthcare professional functioning within the scope of his or her license provides this counseling. Nutritional counseling is often required for members with conditions such as diabetes, heart disease, kidney disease, obesity, eating disorders, or other nutrition related conditions. Nutritional counseling begins with assessing the person’s overall nutritional status, followed by an individualized prescription for treatment. The dietitian or health professional takes into account a person’s food intake, physical activity, course of any medical therapy including medications and other treatments, individual preferences, and other factors. Nutritional counseling of individuals with eating disorders as part of a multidisciplinary approach to treatment, is supported by the American Psychological Association, the Academy for Eating Disorders, and the American Academy of Pediatrics. A multidisciplinary, coordinated approach to treatment includes at a minimum a physician, qualified health care professional, therapist and nutritionist who, preferably, all have specialized knowledge and training in eating disorders. Unique to the Registered Dietitian (RD) is the qualification to provide Medical Nutrition Therapy (MNT). MNT is an essential component of comprehensive nutrition care. Disease or conditions may be prevented, delayed, or managed, and quality of life improved in individuals receiving MNT. -
Clinical Coding Solutions CONSISTENT QUALITY & TIMELY COMPLETION
SERVICE BRIEF Clinical Coding Solutions CONSISTENT QUALITY & TIMELY COMPLETION ABOUT US iMedX was founded in 2002 and since then has become a market leader in the global clinical documentation industry serving over 200 Coding Customers. iMedX has over 3000 employees globally and counts some of the most prestigious acute medical and surgical hospitals in Australia and the US as their clients. Where relevant iMedX can leverage best practice from our parent company. Since 2005 iMedX Australia has had an ongoing relationship with health care facilities of all complexity and sizes through the provision of coding services, and an outsourced medical transcription services offering. Our aim is to partner with you, and to provide tailored solutions that will inform training, development, and best practice in coding accuracy and revenue outcomes for years to come, in accord with the high-quality care delivered to patients and patient complexity. CODING SERVICES OFFERED Discover a coding resource that meets your goals, operates smoothly within your system, and satisfies your need for dependable service. iMedX is structured and staffed to serve the healthcare industry exclusively, but more than that, our fresh approach ties our objectives to yours, netting you enhanced compatibility, compliance and performance. Remote Coding Services Onsite Coding Services Clinical Coding Education Plans and follow (includes producing documentation queries) (includes producing documentation queries) up Education post audit Onsite and Remote Coding Coding Audits including pre & Coding Optimisation Coding and Billing Audits Auditing and Coder Education post third party payer audits THE IMEDX TEAM AUDIT WORKFLOW Led by Karen Dawson with over 25 years experience we have a Below is a summary of a typical Audit workflow for iMedX Clinical team of highly experienced Clinical Coders and Health Information Coding Audits. -
National Clinical Coding Training Handbook 2017-18 Clinical Classifications Service
National Clinical Coding Training Handbook 2017-18 Clinical Classifications Service Copyright © 2017 Health and Social Care Information Centre. The Health and Social Care Information Centre is a non-departmental body created by statute, also known as NHS Digital. National Clinical Coding Training Handbook 2017-18 Contents 1 Introduction 3 1.1 Purpose of document 3 1.1.1 Audience 3 1.1.2 Background 4 2 Clinical Coding Standards Course 4 2.1 Pre-requisite skills, knowledge and experience 4 2.2 Booking a place on the Clinical Coding Standards Course (CCSC) 5 2.3 Clinical Coding Standards Course Details 6 2.3.1 Course Overview 6 3 Clinical Coding Standards Refresher Course 12 3.1 Pre-requisite skills, knowledge and experience 12 3.2 Booking a place on the Clinical Coding Standards Refresher Course (CCSRC) 13 3.3 Clinical Coding Standards Refresher Course Details 14 3.3.1 Course Overview 14 4 NCCQ (UK) Revision Programme 18 4.1 Pre-requisite skills, knowledge and experience 19 4.1.1 Mandatory Pre-requisites 19 4.1.2 Desirable Pre-requisites 19 4.2 Booking a place on the NCCQ (UK) Revision Programme 20 4.3 NCCQ (UK) Revision Programme Details 21 4.3.1. Programme Overview 21 5 Other Useful Information 27 5.1 The Health Informatics Career Framework (HICF) 27 5.2 Informed: An introduction to the use of informatics in healthcare 27 5.3 SNOMED CT Foundation Course 27 5.4 Introduction to SNOMED CT Webinars 27 5.5 NHS Data Dictionary eLearning 27 Copyright © 2017 Health and Social Care Information Centre. -
The Healthcare System in Saudi Arabia and Its Challenges: the Case of Diabetes Care Pathway
Journal of Health Informatics in Developing Countries www.jhidc.org Vol. 10 No. 1, 2016 Submitted: October 6, 2015 Accepted: January 17, 2016 The Healthcare System in Saudi Arabia and its Challenges: The Case of Diabetes Care Pathway Sarah Hamad ALKADI King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia Abstract. The advances of Information Technology (IT) play an important role globally in improving quality and capacity of healthcare sector. IT helps the health professions in managing resources and increasing productivity effectively. Although the conversion from paper to electronic patient records (EPR) conveys many benefits for both caregivers and caretakers, but also has brought many challenges in different aspects. Hospitals have implemented EPR to different degrees. They have used a set of standards in order to insure that data is accurately and consistently processed. Even though, the standardization of how data are captured, exchanged and used includes a set of complications that should be discovered to provide better health data quality for patients with multiple healthcare providers. Therefore, through an analysis of the EPR systems utilization in Saudi Arabia and the diabetes care pathway, three factors have been determined. These factors affect the workflow of the implementation and utilization of health information system (HIS) in terms of capturing, sharing and using its data efficiently. Keywords. HIS, EPR, information sharing, social factors, standards, health information management, diabetes care pathway, health informatics, data capturing, data sharing, Saudi Arabia. 1. Introduction The technology investment in health sector has importance in the management of healthcare services delivery in the developing countries. It is necessary to enhance the utilization as well as the implementation of HIS through standardizing the medical data in order to have a better data quality and more reliable system. -
Certificate of Attendance
Certificate of Attendance Advanced Clinic: Podiatry CPT Coding March 11, 2004 _____________________________________ NAME Lolita M. Jones, RHIA, CCS Presenter The American Health Information Management Association (AHIMA) has approved this program for two (2) continuing education clock hours in the External Forces content area. Retain this certificate as evidence of participation. Advanced Clinic Podiatry Surgery Advanced Clinic: Podiatry Surgery CPT Coding Author: Lolita M. Jones, RHIA, CCS Lolita M. Jones Consulting Services 1921 Taylor Avenue Fort Washington, MD 20744 (V) 301-292-8027 (FAX) 301-292-8244 Coding Training: www.hcprofessor.com E-mail: [email protected] All CPTDistributed Codes ÿ 2003 American by HCPro, Medical Inc.Association * Lolita M. Jones Consulting Services 1 Advanced Clinic Podiatry Surgery TABLE OF CONTENTS Disclaimer 3 About Lolita M. Jones Consulting Services 4 I. Introduction 9 II. Clinical Coder: Skeletal Anatomy of the Foot 10 III. Toe Modifiers 15 IV. CPT Coding Tips 16 V. Case Studies 17 VI. Sample CPT Audit Findings 50 VII. Case Studies Answer Key 52 All CPT Codes 2003 American Medical Association * Lolita M. Jones Consulting Services 2 Advanced Clinic Podiatry Surgery Disclaimer Advanced Clinic: Podiatry Surgery CPT Coding is designed to provide accurate and authoritative information in regard to the subject covered. Every reasonable effort has been made to ensure the accuracy of the information within these pages. However, the ultimate responsibility lies with the user. Lolita M. Jones Consulting Services and staff make no representation, guarantee or warranty, express or implied, that this compilation is error-free or that the use of this publication will prevent differences of opinion or disputes with Medicare or other third-party payers, and will bear no responsibility or liability for the results or consequences of its use. -
HIPE Clinical Coder Resources Report
HEALTHCARE PRICING Healthcare Pricing Office OFFICE Clinical Coder Resources The Evolving Role of the Clinical Coder A qualitative study carried out by the HPO October 2019 Clinical Coder Resources • The Evolving Role of the Clinical Coder HEALTHCARE PRICING OFFICE Acknowledgements The Project team at the Healthcare Pricing Office would like to sincerely thank all the hospitals and individuals who gave freely of their valuable time to consult with us and advise us on this project. The dedication of all staff working within the HIPE system is also acknowledged. With the increasing recognition of the critical role of the HIPE teams in hospitals we are grateful for their hard work and commitment to the system over many years. Thank you. The Project Team , HPO, Brunel Building, St. John’s Road West, Dublin 8. Clinical Coder Resources • The Evolving Role of the Clinical Coder Table of Contents Executive Summary ……………………………………....................................……………………..2 Key Recommendations …………………………………...................................……………….……3 Introduction ……………………………………………....................................……………...….……4 Background ………………………………………………....................................…………….………5 The Project ………………………………………………...................................…………….……….7 Methodology ………………………………………………...................................………….….……..8 Findings ……………………………………………………....................................………….…….....9 1. Role of HIPE Clinical Coder …………………………............................................….……9 2. Staffing and Structures -
Coding Education Newsletter
Coding Education Newsletter Issue 10, March 2014 Coding queries & audit Inside this issue discussion cases Coding queries The March 2014 coding queries and audit discussion cases Audit discussion cases are now available to view on our website: ACCD http://www.clinicalcoding.health.wa.gov.au/news/ Data Quality Coding queries Clinical review: Generalised 1. Retained placenta following missed abortion Anxiety Disorder 2. Borderline diabetes Coding tip: Incontinence Audit discussion cases Back to basics: Multiple drug 1. Discrepancy between clinical diagnosis at use gastroscopy and histopathology findings Coder spotlight: Susanne 2. Deep wound repair with layered suturing technique Forbes from Mount Hospital 3. Adverse effect (osteitis pubis) of radiotherapy Contacts Coding Education Team website www.clinicalcoding.health.wa.gov.au Editorial queries: [email protected] 1 Australian Consortium Clinical review: for Classification Generalised Anxiety Development (ACCD) Disorder (GAD) A reminder for all coders to ensure they are Generalised Anxiety Disorder (F41.1) is a registered on the ACCD Classification mental health condition in which a person is Information Portal (CLIP) to receive often worried or anxious about many things notification when national coding decisions and finds it hard to control this anxiety. are published. Some recent decisions are The cause of GAD is unknown. Genes may being finalised for publication in the near play a role, and stress may also contribute. future. It is a common condition, affecting about 3% of people. Anyone can develop this To register on the ACCD CLIP, visit: disorder, even children. http://www.accd.net.au/Clip/account/Accou The main symptom is frequent worry or ntDetails.aspx?action=Register tension for at least six months, even when there is little or no clear cause. -
Improving the Quality of Clinical Coding Through the Training Of
Research Article iMedPub Journals Journal of Hospital & Medical Management 2020 www.imedpub.com ISSN 2471-9781 Vol.6 No.1:1 DOI: 10.36648/2471-9781.6.1.45 Improving the Quality of Clinical Kiongo JG1*, Yitambe A2 and 2 Coding through the Training of Health Otieno GO Records and Information Officers 1 School of Nursing and Public Health, Chuka, Nairobi, Kenya in Selected Hospitals, Nairobi City 2 Department of Health Management and Informatics, School of Public Health, County, Kenya Kenyatta University, Kenya Abstract *Corresponding author: Kiongo JG Clinical coding quality is increasingly becoming an important arm in health and [email protected] statistics. The objective of this research was to establish whether training could improve the quality of clinical coding in Nairobi City County Hospitals. A before- School of Nursing and Public Health, Chuka and-after interventional design was used for the study. The study was conducted at University, Kenyatta Nairobi, Kenya Mbagathi County Referral Hospital and Mama Lucy Kibaki Hospital, with the latter acting as the control group. The study took the form of a baseline and two follow- Tel: 0722682330 up studies. The intervention was training on ICD-10. A sample of 612 subjects with 306 cases from each hospital was audited. Pretesting was conducted at Mama Lucy Kibaki Hospital. Data analysis was done using Statistical Package for Social Science (SPSS) Version 25. Fisher’s Exact and Paired T- test were conducted to establish Citation: Kiongo JG, Yitambe A, Otieno the significance of differences between the two groups. The study revealed a low GO (2020) Improving the Quality of Clinical proportional (52%) of files were coded in MCRH than in MLKH (62%) therefore, Coding through the Training of Health biasing the intervention to MCRH. -
Electronic Medical Records (Certificate) : Electronic Health Records and Security
Electronic Medical Records (certificate) : Electronic Health Records and Security Lesson 1 Overview The first lesson in your textbook begins with an introduction to Electronic Health Record (EHR). This chapter begins with the explanation of an EHR, who is able to document in the EHR, and the owner of the EHR. Further, the chapter discusses the transition from paper records and functions of the electronic software. Lastly, the chapter ends with both the advantages and disadvantages of EHR. 1.1 Describe the current use and contents of the EHR and describe advantages and disadvantages of EHR Assignment 1: Introduction To Electronic Health Records READING ASSIGNMENT Read this assignment. Then read Chapter 1 in your textbook. History of Medical Records A patient’s medical record is a complete physical collection of an individual’s healthcare information. Medical records started as early as 200 BCE in China and have been used throughout history to document communicable diseases. Originally keeping medical Copyright Penn Foster, Inc. 2018 Page 1 Course Version: 1 records weren’t required, but federal laws have been put into place that require all patient care to be documented in a medical record. Paper records are few and far between and most medical records are found within an EHR. Contents of EHR A health record is a combination of all the health information and documents of a single individual. Each time a patient is seen in the clinic or contacts the clinic, it should be documented within the medical record. Keeping accurate and up to date records is essential for quality patient care. -
ICD-10 Faqs FAQ Review
Welcome to ICD-10 FAQ REVIEW Topics for Discussion . ICD-10 Overview . About ICD-10 . Why ICD-10 Matters ICD-10 . General ICD-10 FAQs FAQ Review . Split Claims FAQs . WV ICD-10 Provider Testing FAQs . Resources . Contact 1 ICD-10 Overview . World Health Organization developed ICD-10 in 1994 . Later adopted by Health and Human Services (HHS) and Centers for Disease Control and Prevention (CDC). ICD-10 is a provision of Health Insurance Portability and Accountability Act (HIPAA) regulations. HIPAA covers entities that include health care providers, payers, clearinghouses, billing services and others that must transition to ICD-10. Moving from ICD-9 to ICD-10 – U.S. is the last industrialized nation to adopt ICD-10 . ICD-9 is outdated - limited capacity, capability and unable to serve future needs . ICD-10-CM and ICD-10-PCS code sets . ICD-10-CM replaces ICD-9-CM (Volumes 1 and 2) . ICD-10-PCS replaces ICD-9-CM (Volume 3) . ICD-10 has no direct impact on Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) 2 ICD-10 Overview (Cont.) . For services rendered on or after October 1, 2015 . All claims must use ICD-10 codes . Claims using ICD-9 codes for services rendered on or after October 1, 2015 will NOT be accepted . For services rendered before October 1, 2015 . All claims must use ICD-9 codes . Systems must accommodate BOTH ICD-9 and ICD-10 codes . Effective with the October 1, 2015 compliance date . Significant code increase from ICD-9 to ICD-10 . Increasing from 14,000 to approximately 69,000 ICD-10-CM codes . -
Kareo User Manual
Kareo User Manual Table Of Contents 1. GET STARTED ............................................................................................................................................................................................. 1 1.1 Installation ................................................................................................................................................................................... 1 1.1.1 System Requirements .........................................................................................................................................................................1 1.1.2 Download and Install Kareo ............................................................................................................................................................. 2 1.1.3 Software Updates ............................................................................................................................................................................... 2 1.2 User Login .................................................................................................................................................................................... 3 1.2.1 Kareo Login with User ID/Password ............................................................................................................................................... 3 1.2.2 Password Change ............................................................................................................................................................................... -
1 the Business of Medicine
Chapter 1 The Business of Medicine Coding as a Profession language, a patient’s condition, or the care provided can change code selection completely. Each time you receive health care, a record is maintained of the resulting observations, medical or surgical inter- Technicians who specialize in coding are medical coders ventions, and treatment outcomes. This medical record or coding specialists. Medical coders assign a code to includes information concerning your symptoms and each diagnosis, service/procedure, and (when applicable) medical history, the results of examinations, reports of supply, using classification systems. The classification X-rays and laboratory tests, diagnoses, and treatment system determines the amount health care providers plans. will be reimbursed if the patient is covered by Medi- care, Medicaid, or other insurance programs using the At its most basic, coding is the process of translating system. this written or dictated medical record into a series of numeric or alpha-numeric codes. There are sepa- If the medical record is inaccurate or incomplete, it rate code sets to describe diagnoses, medical and will not translate properly to the language of codes and surgical services/procedures, and supplies. These reimbursement for services may be lost. The coder must code sets serve as a common “shorthand” language to evaluate the medical record for completeness and accu- ease data collection (for example, to track disease), to racy and communicate regularly with physicians and evaluate the quality of care, and to determine costs and other health care professionals to clarify diagnoses or reimbursement. to obtain additional patient information. Coders may use computer programs to tabulate and analyze data to Coders may use several coding systems, such as those improve patient care, better control cost, provide docu- required for ambulatory settings, physician offices, mentation for use in legal actions, or use in research or long-term care.