Sample Clinic Encounter Coding
Coding is not just about assigning numbers to disease and surgical procedures. It is also about data analysis and abstracting information. One of the first steps you should take before starting to code the conditions and procedures is to validate you have the correct patient account open. Review the patient name, account number and the DOS. If you are using an encoder, verify that same account number and DOS is reflected on the encoding screen. Whether coding from paper charts, digital images and/or electronic medical records, screen all documents to assure they reflect the same demographic information. Also check to assure the sex and age of the patient matches the disease processes and surgical procedures. Validate the account is set up to reflect the correct site of service. Following these steps will assist your facility in preventing delayed, denied, or errant claims.
|
Hospital based clinics may be located within the hospital itself. They may also be external to the hospital.
|
|
Clinic encounters may be as simple as teaching a patient how to complete their own injections.
|
|
|
Treatment rooms within clinics have the standard equipment required to provide all ranges of services routinely provided within that site of service.
|