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, the coder should make sure to properly document the patient's blood pressure, height, and weight. This should be done properly so that the future medical professionals looking over one's health can do a good review of a patient's health history. The changes in the patient's body will be easily seen through this documentation.

The coder should be prepared to record using codes. This means to say that the coder will have to decide on the codes in a way that other coders will not be able to upcode or downcode it. If it gets upcoded or downcoded, the result will be a skewed statistics or revenue loss. The documentation will not help the patients get better too

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.

Modifiers are very important for this too. That is why it is only recommended for the person to focus and not confuse the modifiers. A modifier is usually being used because there is no CPT code which can accurately describe the work that was done. One modifier is meant for reduced services while the other is for discontinued procedure.

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.

There are private payers too. They are those who do not rely on insurance policies. A coder will have to work properly with the private payers too. They will have to do a proper documentation with hospital coding for the patient's sake. Significant things should be cited in the record.




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