Hospital Cards and Coding - Smoky Hill FMRP医院卡编码烟山FMRP.pptVIP

Critical Care Can be performed in any setting (inpatient, ER or office) Not billed just because a patient is in the ICU Time-based codes-documentation of time is required Direct delivery of medical care for a critically ill or injured patient Time spent providing critical care is based on total time spent engaging in work directly related to the individual patient Critical Care Physician is not required to be at constant bedside, but may be involved in patient care decisions on the same floor or unit Time spent outside the unit or floor may not be reported as critical care since the physician is not immediately available to the patient Involves high complexity decision making to assess, manipulate and support vital system functions to prevent further life threatening deterioration of the patient’s condition Assistant Surgery Billable by Resident if not related to rotation or covering rotation for another resident Hospital card required (mainly for tracking) Billing is done from surgery report and surgeon’s billing Charge is typically 25% of the surgeon’s fee Billable by Resident if rotation service but established patient of the resident is the recipient of the surgery Outpatient Procedures Billable by the Resident if not related to rotation or covering rotation for another Resident Hospital card required (mainly for tracking) Questions Lynn-make the red items pop in * Evaluation Management Services July 7, 2009 Brenda Edwards, CPC, CPC-I, CEMC Coding Compliance Specialist KaMMCO Medical Record Documentation Records pertinent facts, findings and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments and outcomes Chronologically documents the care of the patient Is an important element contributing to high quality care. Golden Rule of Coding: If it is not documented, it is not done and therefore not billable! Accuracy is of the Utmost Importance Legibly document what you have done. S