What Is Principal Diagnosis

-Inpatient coders have certifications allowing them to work exclusively for hospitals or facilities. An expertise in medical record review is a must, along with an up to date status with coding rule changes, regulations and issues for medical coding, reimbursements and compliance under MS-DRG and Inpatient Prospective Payment Systems (IPPS). Coders should have experience as well as expert knowledge in abstracting information from medical records for ICD-9CM vol. 1-3, specialized payment in MS-DRG and IPPS.

Unconfirmed means not confirmed due to truth or legitimacy. Meaning if the doctor can’t fully determine if the diagnosis is truthful or valid, considering what the patient’s chief complaint is, they can’t medically code it. If a patient comes into the ER with complaints of chest pains, and the provider wants to exclude heart attack. The doctor would document the chief complaint and the symptoms that are present at the time of ER visit as the leading diagnosis and diagnose the heart attack as the unconfirmed diagnosis. Then the doctor would document the heart attack as the unconfirmed diagnosis

"Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS." (Aapccom, 2015) It is very important that billing coders have a full understanding of how to properly use medical codes to prevent denial of claims submitted.

4. The symptoms the client described that were consistent with the diagnosis. Describe at least 2 symptoms from the diagnostic criteria.

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.

In the daily changes of healthcare, health information technology is evolving rapidly. The generation of coding is making significant developments along the years as well. The 3M-encoder system provides number of essential options to coders in just one click. It provides sophisticated, easy-to-learn solution for accurate, complete, and compliant coding and grouping. Coders need to be acquainted with these references because they provide back up through the articles in each one of them. 3M Coding and Reimbursement System, 3M Coding Reference, and 3M Coding Reference plus have articles for coders to read and get answers to use the appropriate codes. (Prophet). Due

Department Organization: This 358 hospital bed acute care facility. The HIM department is staffed with twenty one individuals who hold various positions. There is one with a RHIA credential, and two with RHIT credential. The other members of the department include Certified Coding Specialists (4), Certified Coding Associates (1), Birth Recorders (1.5), Clerks (2.2), Technicians (6), System Technician (1), Registry (.8) and Document Specialists (2.2) with many tasks shared among the entire team. The information flow begins with the patient discharge. A new chart is created for each discharge. The chart is assembled, coded and then analyzed by senior HIM Specialist for deficiencies. If the chart is complete the chart goes to the main file. If not, complete MD is notified.

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.

The patient must pay close attention to signs and symptoms in this stage. Signs may

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

As viewed by many HIM professionals Computer-assisted coding is a valuable tool for enhancing the effectiveness of coding and billing. CAC software scans medical documentation in the electronic health record (EHRs) using a natural language processing (NLP) engine, identifying key terminology and proposing codes for that specific treatment or service. Human coder then revised these codes. CAC can also investigate the background of key words to conclude whether they need coding.

2. Which patient findings/observations lead you to your primary diagnosis? How do they relate to the primary diagnosis? (1 point)

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 codes are assigned to procedures and diagnoses to bill insurance companies for the services doctors and other health care workers provide to patients. Diagnosis codes must be correctly linked to procedures to establish medical necessity.

Diagnosis: Knowing the futility of treating the symptoms, a clinician begins with a list of observable symptoms and uses cause and effect to seek out the underlying common cause for all of them, the “disease” or core problem.