Medical records documentation and billing essay

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Medical records documentation and billing essay

Discuss two differences between inpatient and outpatient coding. Outpatient coding is much less complicated than inpatient coding. First, outpatient coding is limited to a length of stay less than 24 hours whereas inpatient stays are longer due to the intensity of services.

During an inpatient stay, the hospital charges based on the amount of mime and effort spent on nursing a patient back to health so when it comes to normal birth vs. When it comes to inpatient coding, coders have to be very attentive in order to correctly code the reason for the principal diagnosis because it is crucial to the MS-DRUG formula.

As for the outpatient coding, the first listed diagnostic code indicates the reason for the encounter. We will write a custom essay sample on Medical Billing and Coding Order now More Essay Examples on In conclusion, the outpatient coding summarizes all diagnoses and typically includes a single reoccurred whereas inpatient coding requires daily coding of each service on each day of hospitalizing.

Discuss coding for obstetrics, including items covered by the global fee for antimatter and postpartum periods of normal pregnancy.

Global coding for obstetrics is basically for the services and supplies needed for the antimatter, delivery, and postpartum period of a normal pregnancy. The antimatter period of pregnancy is the time of pregnancy from conception to the onset of delivery.

The initial and subsequent history, all physical examinations, recording of blood pressure, weight, fetal heart tones, routine urinalysis, and monthly visits up to 28 weeks gestation are included in antimatter care.

After 28 weeks, biweekly visits up to 36 weeks gestation, and weekly visits until delivery are also included in antimatter care. Delivery services included the hospital admission with history and physical, the management of uncomplicated labor, and the vaginal or cesarean delivery.

Medical records documentation and billing essay

Episiotomy and the use of forceps are also included for antimatter care. For postpartum care, normal, uncomplicated hospital and office visits for 6 weeks after either vaginal or cesarean section delivery are included. Two conditions may not be reported together. When assigning modifier to multiple procedures, you have to be careful to not add the modifier to each procedure.

Instead add it to the primary procedure which is the procedure with the highest relative value unit when the multiple procedures are performed on the same day or at the same session by the same provider. In addition, if the second surgery is incidental to a major procedure then both services would be reported but the modifier would only be added to the lesser of the two services.

This modifier has been abused by providers excessively by submitting the surgery and follow up codes separately when the follow up should be already bundled together. Providers who have used the modifier are claiming that the service was a part of another service but doing that is a lie.

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Electronic Medical Records (EMRs) - Introduction This paper will discuss the Mayo clinic and its involvement in National Health Information Network; The Mayo clinic is renowned for its outpatient clinic, and it’s diverse and complex organization.

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