Coding for Evaluation and Treatment

2008 ◽  
Vol 18 (1) ◽  
pp. 9-20 ◽  
Author(s):  
Mark Kander ◽  
Steve White

Abstract This article explains the development and use of ICD-9-CM diagnosis codes, CPT procedure codes, and HCPCS supply/device codes. Examples of appropriate coding combinations, and Coding rules adopted by most third party payers are given. Additionally, references for complete code lists on the Web and a list of voice-related CPT code edits are included. The reader is given adequate information to report an evaluation or treatment session with accurate diagnosis, procedure, and supply/device codes. Speech-language pathologists can accurately code services when given adequate resources and rules and are encouraged to insert relevant codes in the medical record rather than depend on billing personnel to accurately provide this information. Consultation is available from the Division 3 Reimbursement Committee members and from [email protected] .

2022 ◽  
Vol 2 (1) ◽  
pp. 26-31
Author(s):  
Hendra Rohman

Background: Analysis of accuracy and validity fill code diagnosis on medical record document is very important because if diagnosis code is not appropriate with ICD-10, will cause decline in quality services health center, generated data have this validation data level is low, because accuracy code very important for health center such as index process and statistical report, as basis for making outpatient morbidity report and top ten diseases reports, as well as influencing policies will be taken by primary health center management. This study aims to analyze accuracy and validity diagnosis disease code based on ICD-10 fourth quarter in 2020 Imogiri I Health Center Bantul.Methods: Descriptive qualitative approach, case study design. Subject is a doctor, nurse, head record medical and staff. Object is outpatients medical record document in Imogiri I Health Center Bantul. Total sample 99 medical record file. Obtaining data from this study through interviews and observations.Results: Number of complete accurate diagnosis codes is 60 (60,6%), incomplete accurate diagnosis codes is 26 (26.3%) and inaccurate diagnosis codes is 13 (13.1%). Inaccuracies include errors in determining code, errors in determining 4th character ICD-10 code, not adding 4th and 5th characters, not including external cause, and multiple diseases.Conclusions: Inaccuracy factors are not competence medical record staff, incomplete diagnosis writing and no training, no evaluation or coding audit has been carried out, and standard operational procedure is not socialized.


1998 ◽  
Vol 44 (8) ◽  
pp. 1713-1727 ◽  
Author(s):  
Charles B Root

Abstract Medicare will continue to increase its efforts to cut spending through aggressive review of claims and the use of new fraud and abuse regulations. Providers must be especially careful to provide correct procedure codes that define precisely what services have been provided and accurate diagnosis codes that link those procedures or tests to an appropriate diagnosis. Medicare reimbursement rules for clinical laboratory procedures are explained, including the proper use of procedure and diagnosis codes. Coding and payment for new automated test panels are discussed, as well as the economic consequences of using smaller panels. Medicare coverage requirements, including medical necessity, are described, as well as the proper use of advance beneficiary notices and the Medicare appeals process.


2013 ◽  
Vol 20 (4) ◽  
pp. 124-128 ◽  
Author(s):  
Angela Barber

Spelling is a window into a student's individual language system and, therefore, canprovide clues into the student's understanding, use, and integration of underlyinglinguistic skills. Speech-language pathologists (SLPs) should be involved in improvingstudents' literacy skills, including spelling, though frequently available measures ofspelling do not provide adequate information regarding critical underlying linguistic skillsthat contribute to spelling. This paper outlines a multilinguistic, integrated model of wordstudy (Masterson & Apel, 2007) that highlights the important influences of phonemicawareness, orthographic pattern awareness, semantic awareness, morphologicalawareness and mental graphemic representations on spelling. An SLP can analyze anindividual's misspellings to identify impairments in specific linguistic components andthen develop an individualized, appropriate intervention plan tailored to a child's uniquelinguistic profile, thus maximizing intervention success.


PEDIATRICS ◽  
1975 ◽  
Vol 56 (2) ◽  
pp. 329-329 ◽  
Author(s):  
Hugh C. Thompson ◽  
Stanton J. Barron ◽  
John P. Connelly ◽  
Andrew Margileth ◽  
Richard Olmsted ◽  
...  

Historically, medical records have been maintamed by individual physicians to record specific information concerning patients. This information was often understandable only to the writer. The data were of outstanding events. This was thought to be sufficient documentation for patient care. Records are now read by others than the individual physicians. Groups of physicians working together often share the same patients and their records. Patients may have multiple sources of care. Our population has become more mobile which makes it necessary to transfer vast amounts of medical information. The medical record many times is the one instrument which gives a complete and continuous documentation of the patient's medical history. Third-party payers are requesting access to medical records to document services provided. Chart audit is being tested as a mechanism for evaluating physician performance. Records must reflect what the physician does in order to be useful in such an appraisal. Much clinical research on the delivery of health care depends on accurately kept records which are easily interpreted. A chart is also a legal document for the protection of the physician as well as the patient. Thus, records will be used in other than traditional ways. Proper confidentiality must be maintained when such uses are necessary. Physicians generally agree as to the essential content of a medical record. However, there is little unanimity as to the structure of the chart. No one system of keeping records is now appropriate for all situations. The maintenance of adequate charts requires additional cost in both time and money.


2022 ◽  
Vol 2 (1) ◽  
pp. 39-44
Author(s):  
Nurhasanah Nasution

Background: Incomplete filling of medical record files for inpatients at Dr. Reksodiwiryo hospital medical records will be describe health services and the quality of medical record services. Medical record quality services include the completeness of medical record files, accuracy in providing diagnosis and diagnosis codes, as well as speed in providing service information. The requirements for quality medical records must be accurate, complete, reliable, valid, timely, usable, common, comparable, guaranteed, and easy.Methods: This research method is a descriptive with a retrospective approach or looking at existing data. This study was carried out in September 2021. The population was 70 files cases of inpatient digestive surgery. Samples were taken from 27 files of inpatients with appendicitis cases.Results: From the research that has been done, the highest percentage of incomplete identification components is found on the gender item about 81.48%, the highest percentage of incomplete important report components is obtained on the medical resume and informed consent items about 11.1%. The highest percentage of incomplete authentication components was obtained in the nursing degree about 96.3%. The highest percentage of the components of the recording method was obtained by 59.3%, there are several blank sections about 16 files. The percentage of incomplete diagnostic codes and procedures is 100%  Conclusions: the researcher suggested that the hospital can have an Operational Standart on filling out the completeness of medical records files


Author(s):  
Satish C. Sharma ◽  
Harshila Bagoria

Cloud computing is a new breed of service offered over the Internet, which has completely changed the way one can use the power of computers irrespective of geographic location. It has brought in new avenues for organizations and businesses to offer services using hardware or software or platform of third party sources, thus saving on cost and maintenance. It can transform the way systems are built and services delivered, providing libraries with an opportunity to extend their impact. Cloud computing has become a major topic of discussion and debate for any business or organization which relies on technology. Anyone connected to the Internet is probably using some type of cloud computing on a regular basis. Whether they are using Google’s Gmail, organizing photos on Flickr, or searching the Web with Bing, they are engaged in cloud computing. In this chapter, an attempt has been made to give an overview of this technology, its connection with libraries, the models in which libraries can deploy this technology for providing services and augment the productivity of library staff and case studies.


2008 ◽  
pp. 1839-1864
Author(s):  
Elisa Bertino ◽  
Barbara Carminati ◽  
Elena Ferrari

In this chapter, we present the main security issues related to the selective dissemination of information (SDI system). More precisely, after provided an overview of the work carried out in this field, we have focused on the security properties that a secure SDI system (SSDI system) must satisfy and on some of the strategies and mechanisms that can be used to ensure them.  Indeed, since XML is the today emerging standard for data exchange over the Web, we have casted our attention on Secure and Selective XML data dissemination (SSXD).  As a result, we have presented a SSXD system providing a comprehensive solution to XML documents. In the proposed chapter, we also consider innovative architecture for the data dissemination, by suggesting a SSXD system exploiting the third-party architecture, since this architecture is receiving growing attention as a new paradigm for data dissemination over the web. In a third-party architecture, there is a distinction between the  Owner  and the Publisher of information. The Owner is the producer of the information, whereas Publishers are responsible for managing (a portion of) the Owner information and for answering user queries. A relevant issue in this architecture is how the Owner can ensure a secure dissemination of its data, even if the data are managed by a third-party. Such scenario requires a redefinition of dissemination mechanisms developed for the traditional SSXD system. Indeed, the traditional techniques cannot be exploited in a third party scenario. For instance, let us consider the traditional digital signature techniques, used to ensure data integrity and authenticity. In a third party scenario, that is, a scenario where a third party may prune some of the nodes of the original document based on user queries, the traditional digital signature is not applicable, since its correctness is based on the requirement that the signing and verification process are performed on exactly the same bits.


2020 ◽  
Vol 13 (12) ◽  
pp. e237307
Author(s):  
Mahendra Kumar Jangid ◽  
Reyaz Ahmad ◽  
Sujeet Pandre

One of the causes of congenital incomplete duodenal obstruction is the presence of congenital duodenal web with fenestration. This condition requires a high index of suspicion for an early and accurate diagnosis. We present an unusual presentation of duodenal web in a 6-year-old girl who presented with a 3-year history of cyclical and seasonal vomiting and abdominal pain. The diagnosis of congenital duodenal web with fenestration was made on contrast study and endoscopy and was treated surgically by incision of the web.


2020 ◽  
Vol 22 (11) ◽  
pp. 1957-1975
Author(s):  
Rasmus Helles ◽  
Stine Lomborg ◽  
Signe Sophus Lai

Today, websites operate in a modular fashion, outsourcing the surveillance and datafication of users to outside companies, along with security functions, video hosting, and so on. These third-party services (TPSs) function as key enablers of the web, with respect to functionality and the monetization of user activity. Departing from critical data studies and media systems analysis, the article contributes to understanding TPS infrastructures by placing these in a wider context of markets, cultural differences and regulation. Through a study of top-150 websites from the 28 EU countries, the article demonstrates how the use of TPSs varies between different parts of the region and different types of sites, and traces this variation to issues of language, regulatory traditions and differences in online businesses. These insights may inform current debates about surveillance capitalism and big data, by linking different forms of commodification of users’ behavioural data to broader social and cultural structures.


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