Diagnosis Coding Research Paper

Why are you interested in studying medical coding? Where do you see yourself working after you graduate and pass the certification exam? What is the difference between a CPC and a CPC-A certification through the American Academy of Professional Coders (AAPC)?

I think all coding is important, but since I have to choose between level of specificity and impending or threatened conditions. I would say level of specificity is more important. Level of specificity refers to the amount of detail included in the code and is important in diagnosis coding. Mrs. Pavey mention we can't code impending or threatened instead code the signs and symptoms. In order to prove medical necessity and get reimbursement I will say both are important. I think all topics are relevant to learn coding. We need to learn it all if we are going to be coding.

Read the article Diagnosis Coding and Medical Necessity: Rules and Reimbursement by Janis Cogley located on the AHIMA Body of Knowledge (BOK) at http://www.ahima.org.

MEDICAL CODING QUALIFICATIONS AND CERTIFICATION Medical Coding is a career in which professionals use numeric and alphabetic codes to help submit and process medical claims. The coder abstracts information from the patient records and combines that information with coding guidelines to assign the right code for the information provided by physicians, hospitals, and other healthcare professionals. Insurance companies look at these codes to understand the diagnosis, treatment, and prescriptions for proper payment of these services. Accordingly, the medical coding profession requires a worker to have a strong grasp of numbers and be detailed oriented. (AC Search & Media, Inc.)

A Combination code is a single code that is used to classify two diagnoses together. A combination code can also be used when we code for external causes, to help identify the sequence of events for how the injury occurred and if it was an accident or intentional. Multiple coding is needed when the patient has another condition that does not relate to the main diagnosis, then we will need to use an additional code. When we look up a disease in the ICD-10 book, the tabular list may have instructional notes to tell us to use multiple code.

The article Alternate Health Care Coding Systems gave brief descriptions and examples of alternate coding systems. All the alternative coding systems and medical nomenclatures are used as another way to properly diagnose patients, and proper billing and reimbursement. Although, I was a bit confused retaining all the information but in my take away from the readings is that nomenclatures and coding systems are used to allow medical terminology, codes, procedures, and diagnoses to be more descriptive. Two patients could have the same exact tumor but depending on size and where the tumor originated from could be the difference in coding that certain patient.

Combination codes identify both the condition and the additional specificity requires coders to place greater emphasis on abstracting information from the medical records. Multiple coding is required to describe etiology and manifestation when infectious and parasitic disease produce a manifestation with another body system.

When it comes to medical coding, attaching the medical codes in the first and most important. If an attached code is incorrect when put on the record a patient may be charged with the wrong procedure. (LinkedIn, 2018) says, “the accuracy and adequacy of coding and documentation

Most of the three character codes you’ll see will be category headings. These codes would then be expanded into four, five, or six characters to add even more specificity about diagnosis.

A combination code is a single code that can be used to classify two diagnoses, a dianosis with an associated complication, or a diagnosis with an associated manifiestation. These can be found by looking at the subterm entries in the ICD-10-CM index or by following the "includes" and "excludes" notes in the tabular list of ICD-10-CM. Multiple codes would need to be used for a complex diagnosis. This can be indicated by phrases such as "due to", "incidental to", "with", and "secondary to". Multiple codes should never be used when there is an available combination code that can indentify all of the elements of a given diagnosis. An additional, secondary code should be used when there isn't a combination code that describes the complications

specific codes are charged to the patient and specific diagnoses entered on a claim for a patient.

Medical coding is a very detailed process in which health care professionals use to code an insurance claim, to submit for reimbursement of services. In the following scenario, my task would be to explain the process and steps I took, to code patients cases using ICD-9. When coding it’s very important to code correctly to avoid delays in reimbursement and proper reimbursement. The following will explain the steps I took to perform proper medical coding.

One example is recognizing conditions that may affect a certain region of the body, such as a patient being diagnosed with rhinosinusitis and was prescribed a two-week regimen of antibiotics. From the medical report, the biller/coder must be able to apply proficient knowledge of medical terminology. The coder should be able to break down the medical term rhino-sinus-itis. The anatomy for rhino is nose, the physiology of the nose is the lined membranes which is sinus and the condition is (-itis, the inflammation of). Understanding the basic body function enables the biller/coder to translate the provider’s medical documentation for correctly coding and billing. The diagnosis code was always the same for each billing would be for the initial evaluation of a new patient outpatient or billing and coding for an established patient

As mentioned earlier, this study used the ICD-9-CM coding classification system to define BV cases. A female service member was defined as “BV case” if she had a diagnosis of BV based on the ICD-9-CM code 610.10 (vaginitis and vulvovaginitis, unspecified) in either the first or the second diagnostic position of an outpatient or inpatient encounter medical record from the DMSS in the preceding years of the index date for CT or NG infection. On the basis of the evidence currently available, BV is a common disorder among women and recurrent BV episodes are frequent. However, there is no universally accepted definition of recurrent BV by a number of researchers (Morris et al., 2001; Eschenbach, 2007; Lambert et al., 2013). Wilson (2004) reported

The outmoded coding professional’s role was to describe and apportion diagnosis, procedure, and other medicinal service codes using ICD-9-CM and HCPCS/CPT coding classifications while referencing the Coding Clinic for ICD-9-CM, Coding Clinic for HCPCS,