Level Of Specificity

Quality physician documentation is not only essential to providing superior clinical communication, but also allows for the delivery of useful data that “supports quality metrics, acuity of care, billing, and accurate representation of medical conditions” (Rosenbaum et al., 2014). The Centers for Medicare and Medicaid Services (CMS) uses a system to classify Medicare patient’s hospital stays into various groups in order to facilitate payment of services called Medicare Severity-Diagnosis Related Group (MS-DRG). Some payers also use all patient refined (APR)-DRG reimbursement systems. MS-DRG groups are outlined by a specific collection of patient characteristics which include areas specific to the “principle diagnosis, specific secondary diagnoses,

- Taking into account the patient physical, social, psychological and spiritual health allow for allow for a more competent and effective patient care.

broad range of individual patients. The patient should be able to benefit maximally from the care he/she receives.

Criteria: setting evaluation, contact was it direct or indirect, is patient a child or infant, service provided, is the patient established/new. Service level consist of three components, which is the history, exam, and decision made at the time of visit. Patient that has seen the doctor for three year is established. One that has not seen the doctor is new. There are four levels of making a decision. HPI factors relate to the issue the patients is dealing with. ROS factors relates to the sign of illness. PFSH factors deals with the history of the patient and history of the

During the assessment I was keen to make sure that the patient was clear about what the procedure involves and the routine of the day, throughout the assessment I was concerned that while I believe the patient did understand the Procedure, I was concerned as to whether all the possible complications and post procedure instructions were fully understood, I was also concerned as to whether the patient had the ability to communicate any concerns she may have, the patient also has hypertension. The priorities of care with this patient is monitoring her blood pressure throughout her time within the unit, the ability to understand the procedure and capacity to consent, also communication barriers both of which relate to her learning disabilities. I believe that the key priority for this patient is her learning disabilities and communication barriers, as it is vital that the patient is entirely aware of the procedure.

quality of care. It also requires a review of the process of care and changes in the patients

One thing I would like to highlight is the importance of including the patient and their families as part of the diagnostic team. It should be remembered it's the patient that primarly understand the symptoms more than anyone.

In addition to the different prospective payment systems, diagnosis-related groups monitor quality of care and the uses of services in a hospital. Diagnosis-related groups are an “inpatient classification that categorizes patients who are similar in terms of diagnoses and treatment, age, resources used, and lengths of stay.” Diagnosis-related groups are important to how much reimbursement a healthcare

Through use of the Universal Intellectual Standards of Quality Thinking (UISQT) the nurse should use the standards, relevance and significance, to organize and categorize the patient's information and separate the important assessment data that will help to tailor an appropriate plan for the patient (Wilkinson, 2011, p. 70). These skills are important because through relevance one can separate what information is relevant to the patient's problem and through significance one can sort out what data is most important and what data is normal for the relevant data. The assessment data of S.P.’s vital signs and body mass index are normal. The important data sorted for S.P. includes her age, medical history, oxygen saturation and 50-pack-year smoking history, fall at home leading to an intracapsular fracture of the hip at the

Differential diagnoses are developed by a clinician upon learning of the chief complaint. One must begin to develop the possibility of potential diagnoses mentally to guide the care provided to the patient. These potential diagnoses are developed by the care provider and are often based on one’s past clinical experiences, awareness of the illness and a clear understanding of the patient’s complaint (Goolsby & Grubbs, 2014). The care provider with experience may develop these diagnoses independently and others with less experience may utilize evidence-based resources and clinical guidelines to aid in this process (Goolsby & Grubbs, 2014). The process for reaching a final diagnosis requires further investigation and use of physical assessment

It is nearly impossible to avoid clinical denials entirely. Therefore, the health information management (HIM) department should have strong procedures built as a defense against clinical denials. Ensuring the claim is sent to the payor appropriately is complicated since coders “must not only ensure they are within the parameters of official coding guidance, but also they must review the record to justify the clinical significance” (Brownfield et al., 2014). For example, universal coding guidelines in ICD-10-CM explain that coders should not assign codes for signs and symptoms with an established diagnosis if the signs and symptoms are integral to the established diagnosis. For example, if the patient is experiencing lower back pain and the

Of the coding topics discussed in this unit , I believe that Level of Specificity , which is the level of detail . And detail is very important in diagnosis coding . Coding must be done to its highest level to receive maximum reimbursement for claims submitted. I also believe that combination codes are very important also, because the combination code can only be assigned when that code fully identifies the diagnostic condition involved, or when the Alphabetic Index so directs. I think they are important because it could very well make the coding very confusing . I also think that there are no areas of coding that are not as relevant as the other , I believe we should know everything possibly to be known about coding , to give us the

This forces the professional to give a diagnosis to individuals even when they know it, it is clashes with their values, so that the sessions could be covered by the insurance. This has a lot to do with money and societal systems of patient treatment.

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.

It requires across-the-board foundation of knowledge to provide services in this unique area. Superiority of care is needed to treat patients with multifaceted and or unusual conditions and warrants strong communication and collaboration between the urgent care providers, the specialists and the primary physicians