Coding Clinic
Valuable reference tool for coders that is published by AHA each quarter
CPT
Current Procedural
... [Show More] Terminology
MS-DRGs
Medicare Severity-Diagnosis Related Groups
CPT Assistant
Monthly publication by the AMA that provides coding advice for CPT coding scenarios
Encoder Nosology
Provides coding professionals from the encoder company that are available to help answer tough coding questions
History & Physical
Provides the initial chief complaint and initial impressions of the provider when the patient is first admitted. It also has a comprehensive physical review of the patient's body systems and vital signs, and provides the initial treatment plan, medications, and tests that are being ordered to treat the patient.
Progress Notes
Provide information about what is going on with the patient on a day-to-day basis; they should include the diagnoses that are being treated as well as any information about any changes in the patient's well-being and tests/procedures being performed.
Operative and Pathology Reports
Summarize the invasive procedures performed and any samples that are removed from the patient's body
Pathology report
Provides detailed information from the pathologist of the facility as to the status of the tissues or organs removed from the patient's body
Encoder
Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system
What is the value of utilizing coding software?
It facilitates accurate coding by providing links to coding resources, groups diagnosis and procedure codes to the correct MS-DRG, and provides edits with additional information for the coder to consider when placing codes into the encoder
Principal diagnosis
Diagnosis that, after study, is the reason for the patient's admission to the hospital.
Secondary diagnoses
Additional supporting information for the conditions the patient is being cared for
MCC
Major Complication or Comorbidity [Show Less]