What are the six steps in the procedural coding process?

What are the six steps in the procedural coding process?

6 Key Steps in the Medical Coding Process

1. Action 1. Abstract the documentation.
2. Action 2. Query, if necessary.
3. Action 3. Code the diagnosis or diagnoses.
4. Action 4. Code the procedure or procedures.
5. Action 5. Confirm medical necessity.
6. Action 6. Double-check your codes.

What are the basic steps of procedural coding?

The correct process for assigning accurate procedure codes has six steps: (1) review complete medical documentation; (2) abstract the medical procedures from the visit documentation; (3) identify the main term for each procedure; (4) locate the main terms in the CPT Index; (5) Verify the code in the CPT main text; and …

What documents in medical records can be used for procedural coding?

Terms in this set (8)

• encounter. form.
• history & physical report.
• progress. notes.
• discharge. summary.
• operative. report.
• Pathology. report.
• anesthesia. record.
• radiology. report.

What is the medical assistant’s role in procedural coding?

Medical assistants typically focus on a mixture of clinical and administrative work, or may choose to pursue one or the other exclusively. This can include a wide range of tasks: everything from taking patient vitals, drawing blood, and collecting urine samples to handling billing, scheduling, and recordkeeping.

What is the coding process in healthcare?

Medical coding refers to the process by which healthcare diagnoses, treatments and even equipment are translated into universal alphanumeric codes. Medical coding professionals take data, often drawn directly from patient files and physician notes, and transform it into codes.

What is the process of reviewing medical documentation?

These are the various steps in our medical review process.

1. Collecting and Arranging Medical Records.
2. Sorting and Organizing the Records.
3. Analyzing and Interpreting the Data.
4. Creating an Accurate Medical Chronology/timeline.
5. Creating Medical Case Summaries.

What is the criteria for documentation of medical necessity?

Well, as we explain in this post, to be considered medically necessary, a service must: “Be safe and effective; Have a duration and frequency that are appropriate based on standard practices for the diagnosis or treatment; Meet the medical needs of the patient; and.

How is data accuracy in medical record abstraction?

Data Accuracy in Medical Record Abstraction. The abstraction process results in a summary of information about a patient for a specific secondary data use. Medical Record Abstraction remains a primary mode of data collection in clinical research, quality improvement, performance measurement, disease surveillance, and other secondary data uses.

When to use an abstract in procedural coding?

In procedural coding, an abstract is created to find all the procedures and services performed during a patient encounter and also to ensure that nothing has been omitted from or added to the encounter form or charge ticket that is not documented in the medical record.

Which is benefit of manually abstracting clinical data?

Chart abstraction is a manual data entry effort where organizationally-defined, clinically relevant data elements that are not being electronically converted, are collected from the legacy system and manually entered into the new target system. There are many benefits to manually abstracting clinical information, including:

How is abstraction used in the medical field?

Abstract: to identify data required for a secondary use. Abstraction involves some direct matching of information coding, transforming, interpreting, summarizing, and calculating. The abstraction process results in a summary of information about a patient for a specific secondary data use.