Three Key Components Of Evaluation And Management Code Selection

Through basic observations, health professionals are able to evaluate the performance of an individual’s health status. In relation to Casey, it is noted in her Observation Chart that in the time span of two hours the patient’s health status had changed from being relatively normal (to the patient) to an increased respiratory rate, heart rate and temperature as well as a decrease in blood pressure. It is also noted that the patient has a score of 8 in the pain scale (compared to the score of zero two hours previously), relating to the lower abdomen. Programs such as Between the Flags acknowledges the fact that the early recognition of deterioration of patients can reduce harm to patients through designing and implementing systems which provide a structural response in the event of a deteriorating patient, such as Rapid Response and Clinical Review. There are two phases involved in the rapid response, which includes the afferent phase and the efferent phase. The afferent phase focuses on the overall monitoring and recognising the deteriorating patient whereas

Evaluation of a patient’s outcome, to determine the effectiveness of the treatment that they received while under my care, is

9. The review of systems (ROS) is documented for patient care purposes and also factors into the ________________ for the patient 's visit.

Coding systems are used in the inpatient and outpatient settings for the classification of patient morbidity and mortality information for statistical use. The World Health Organization (WHO) developed the Ninth Revision, International Classification of Diseases (ICD-9) in the 1970s to track mortality statistics across the world. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), is the adaptation the U.S. health system uses as a standard list of six-character alphanumeric codes to describe diagnoses. Globally utilizing a standardized system improves consistency in recording symptoms and diagnoses for payer claims reimbursement, as well as clinical research, and tracking purposes.

These discoveries prompted change and allowed the National Institute of Health and Clinical Excellence (NICE), to set standards to reduce unnecessary detriment to patients. Many tools were introduced to assist in the consistency and accuracy of observations of patients’ physiological conditions. ViEWS (VitalPac Early Warning Score) is a standardized and high-tech scoring system that helps recognize and respond to deteriorating patients. It is the basis of the newest warning system, appropriately named National Early Warning System or NEWS (Featherstone, Prytherch, Schmidt & Smith, 2010).

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,

1. the robustness of the literature in this area, both in terms of assessing quality of care

Assessing and giving a diagnosis has a range of things taken into consideration like how often, how

Diagnostic coding is one of the most critical parts of medical coding. If the correct diagnostic code is not selected, a claim may be denied (Deborah Vines, 2013, pp. 88-125). Using the ICD-9-CM, diagnosis coding became mandatory for Medicare claims since the Medicare Catastrophic Coverage Act of 1988. In 1948, the ICD came under the direction of the World Health Organization, which assisted in tracking deaths and sicknesses to help make statistical assessments of international health and disease trends (Deborah Vines, 2013, pp. 88-125). Medical terminology plays a key role in proper diagnosis coding. You must be able to read and understand the physician’s documentation to identify the appropriate codes for medical conditions that pertain

➤ Diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM

Ashton, C., Kuykendall, David H., Johnson, Michael M. (1999). An Empirical Assessment of the Validity of Explicit and Implicit Process-of-Care Criteria for Quality Assessment. 27(8). 798-808.

CSI is a severity scoring system that uses disease-specific measurements to categorize different levels of a patient’s severity. [51-53] These measurements include patient historical factors, physiologic parameters, and laboratory results. CSI covers a wide spectrum of diseases; more than 3,500 disease-specific severity matrices have been developed. It has been applied to predict patients’ prognosis[46], length of stay, re-hospitalization[54] and service cost[55, 56] and so on. Additionally, it has been used as a control factor in both retrospective [56, 57] and prospective clinical studies [58], which is hallmark of the Practice-Based Evidence (PBE) Research [59, 60]. Compared with traditional randomized control trial (RCT) studies[59], PBE studies simplify inclusion of a larger sample size, promote conducting long term follow-up, and are closer to real practice as opposed to the restrictions placed recruitment in RCTs. Compared with traditional observational studies[59], PBE standardizes confounding factors and makes the study design easier, more reliable, and more reproducible.

More recently, early warning systems have been developed in an effort to recognise the at-risk patient who may be deteriorating

These measurements provide feedback of a patient’s experience with the care offered at a given hospital. These measurements assess a wide range of factors including interpersonal aspects of care, clarity of - and ease of access to - information provided by the physician, speed of medical staff’s response to the patient’s urgent care needs, among other factors. These measurements are used by patients in their subjective evaluation during their process of choosing a hospital for emergency care or

APACHE stands for Acute Physiology and Chronic Health Evaluation and the first system was developed in 1981. The newest APACHE system was developed in 1991. The APACHE III system was designed to predict an individual 's risk of dying in a hospital. It compares each individual 's medical profile against nearly 18,000 cases in its memory before reaching a prognosis that is, on average, 95 percent accurate (Open Clinical website, 2005). This system can be used in the Intensive Care Unit setting and it can predict the patient’s risk of dying in the Intensive Care Unit. This system takes into account several variables such as, diagnosis and psychical conditions upon admission to the Intensive Care Unit, age, pre-existing medical disorders and other variables. A physician gives the system facts, and based upon the facts the system can predict the patient’s risk of passing away. This system does not spit out an answer and healthcare workers have to follow it, it is rather a tool to help healthcare providers make a decision on whether to discontinue “heroic” measures and it allows them to ponder these issues in a realistic way. The Clinical Decision Support System is a system that uses patient data to generate specific advice relevant to the patient’s case. Clinical DSSs are typically designed to integrate a medical knowledge base, patient data and an inference engine to generate case specific advice. (Open Clinical website, 2006). Overall, this system can be helpful when