By Michelle A. Green

3-2-1 CODE IT! is your finished studying source for coding. This publication combines ICD-9-CM, CPT, and HCPCS point II coding options into one handy package deal and provides a degree of aspect appropriate for starting and more matured coders alike. while you're able to earn a coding credential, this ebook will proceed that can assist you arrange and perform. The e-book contains an summary of coding structures, occupation possibilities for coders, the significance of becoming a member of expert corporations and acquiring credentials, the effect of operating with different coding execs, and the way to enhance possibilities for occupation development.

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Extra info for 3-2-1 Code It! , Second Edition

Sample text

This is called medical necessity and requires providers to document services or supplies that are: • Proper and needed for the diagnosis or treatment of a medical condition. • Provided for the diagnosis, direct care, and treatment of a medical condition. • Consistent with standards of good medical practice in the local area. • Not mainly for the convenience of the physician or health care facility. ” The patient record serves as a medicolegal document and a business record. If a provider performs a service but doesn’t document it, the patient (or third-party payer) can refuse to pay for that service, resulting in lost revenue for the provider.

The provider is also responsible for correcting or altering errors in patient record documentation. Health data collection is performed by health care facilities to do administrative planning, to submit statistics to state and federal government agencies, and to report health claims data to third-party payers for reimbursement purposes. org to review resources available at the AHA Central Office Web site. S. clearinghouse for proper use of ICD-9-CM, HCPCS level I (CPT), and HCPCS level II codes for hospitals, physicians, and other health professionals.

Reporting Hospital Data Hospitals and other health care facilities use automated case abstracting software to collect and report inpatient and outpatient data for statistical analysis and reimbursement purposes. Data is entered in an abstracting software program (Figure 1-1), and the facility’s billing department imports it to the UB-04 (or CMS-1450) claim (Figure 1-2) for submission to third-party payers. , procedure index) (Figure 1-3), which are used for statistical analysis. The UB-04 (or CMS-1450) is a standard claim (uniform bill) submitted by health care institutions to payers for inpatient and outpatient services.

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