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Health & Medical Week 1 Medical Terms Live Lecture Notes

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WEEK 1 LIVE LECTURE NOTES
1. Role of hospital coder: Assign codes classification codes to diagnosis,
procedures and services that are performed to the CPT, HCPCS level 2
(procedures and services), ICD-10-CM (diagnosis) and ICD-10-PCS
(procedures). There are 3 tools for coding: coding manuals, encoders and
computers assisted coding (CAC).
2. Medical Coding Process: First of all make sure to be ethical, you cannot
undercode or overcode. Code accurately reflects the services performed to the
patient. Follow the steps for coding. There are steps for CM, PCS and CPT to
follow all of them. It's very important to ensure the quality of coding they are
correctly coded and sequenced. Most important avoid assumptions in coding,
don’t assume the code. Read all the records carefully. Use physician query
process.Next process is called CD Clinical Documentation Improvement program
and the coding compliance program. It makes it easier for the coder.
3. Health Data Collection: Abstract information, go through and confirm the
date of admission, date of discharge, confirm the patient’s age check who is
payer. If it's medicare patient in an inpatient setting that means medicare
guidelines should be followed. There is a different set of coding guidelines for
outpatient as compared to inpatient. It is very important to know the patient status

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and what information needs to be collected and reported not only for
reimbursement but also for statistics. ICD-10-PCS is used only for the inpatient
procedures. And CPT is used to report the surgical and diagnostic procedures in
the outpatient setting.
4. ICD-10-CM index to disease: The alphabetical index consists of the index
of diseases and injuries.It has 2 tables and one special index: the index to
external causes, the neoplasm table aand the table of drugs and chemicals.
Tabular list classify by the body system or the etiology. Disease and injury codes
always have 3 characters most of them followed by a decimal point and between
1 and 4 additional characters. For Example: T36.0X1A. Can have upto 7
characters in our code. For all pregnant womens code will be from chapter 15
starting with O.
5. ICD-10-CM categories, subcategories and codes: there are 3
characters and no further subdivisions it means that is the vald code. Eg :I10
hypertension. No further characters are required. In injury 7th characters are
required so always place that in 7th position the episodic character. Sometimes
we need to add a placeholder X. Coding steps for ICD-10-CM: Identify the main
term, locate them and the alphabetical index, refer to subterm, read and guide by
any instructional terms in that tabular list and assign the code.

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WEEK 1 LIVE LECTURE NOTES 1. Role of hospital coder: Assign codes classification codes to diagnosis, procedures and services that are performed to the CPT, HCPCS level 2 (procedures and services), ICD-10-CM (diagnosis) and ICD-10-PCS (procedures). There are 3 tools for coding: coding manuals, encoders and computers assisted coding (CAC). 2. Medical Coding Process: First of all make sure to be ethical, you cannot undercode or overcode. Code accurately reflects the services performed to the patient. Follow the steps for coding. There are steps for CM, PCS and CPT to follow all of them. It's very important to ensure the quality of coding they are correctly coded and sequenced. Most important avoid assumptions in coding, don’t assume the code. Read all the records carefully. Use physician query process.Next process is called CD Clinical Documentation Improvement program and the coding co ...
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