Question

Review the following lecture: Coding for Medical Necessity Introduction: In order to properly code a bill for medical necessity, it is important to understand the electronic medical record. This record contains information about the patient's health both before and after the treatment and has the data needed to assure a payer that the treatment was necessary. Tasks: Explain the contents of the medical record. Describe SOAP notes-subjective, objective, assessment, and plan. Explain operative reports function in medical necessity coding. Explain National and Local coverage determinations Submission Details: Submit the report as a 5- to 10-page Microsoft Word document. Use APA standards for citations and references Cite a minimum of three outside peer- reviewed sources to sunnort your

Answer 1

1. Contents of electronic medical records (EMR)

As a standard it contains medical history of a patient and the treatment given to them. It also contains:

• Data for billing purposes and for administration use
• Demographic details of patient
• Progress reports
• Parameters of vitals and allergies if any
• Diagnoses, medicine administered and treatment
• Immunization dates
• Laboratory test and radiology reports

https://www.healthit.gov/faq/what-information-does-electronic-health-record-ehr-contain

2. Describe SOAP notes (subjective, objective, assessment, and plan)

It is used to organize the information about patients. The source of information can be EMR.

It is basically use

Subjective: The patient is asked about their ailment and symptoms. Whatever they feel is expressed by them and that is recorded under this head. It is not objective information as is not based on measurements.

It can take a sequence in documentation like: Onset: when they experienced it for the first time, Location: in what body part or area they experience ailment, Character: nature of symptoms or pain etc., Alleviating objects: if anything reduces it, Radiation: is the symptoms radiating in other body parts or are felt localized, Is there any pattern of time when the patient experience, Additional symptoms: apart from chief problem is there any other issues.

Objective: The measurable symptoms through observation, diagnostic tests and other medical reports are documented here.

Assessment: prognosis and diagnosis of ailments is recorded here.

Plan: treatment plan including medication / surgery prescribed, further test to be done, rest etc.

https://www.gapmedics.com/blog/2015/01/02/understanding-soap-format-for-clinical-rounds/

3. Operative reports function in medical necessity coding

Medical necessity means that the procedures performed or line of treatment administered is based in accordance with the necessity for it duly confirmed by existing symptoms and diagnostic reports of patient. Thus operative reports are prepared.

Operative reports are used for existing and future extended in-patient care services. It is also used for payment of services to payers and acts as a source of information for statistics and researches. A medical coder extracts important data form these reports for encoding and feeding in computer systems.

https://cdn.optumcoding.com/upload/pdf/CHOP18/CHOP_CHOP18_eCHOP18%20Sample%20Pages.pdf

4. Explain national and local coverage determinations

A local and national coverage determination: A Medicare Administrative Contractor decides the relevance or need of a particular service offered by providers for patient and thus add it in Medicare. When it is for particular area (jurisdiction) under Medicare Administrative Contractor it is local coverage determinations.

When the guidelines are mandated at the national level it is national coverage determination. It is to be followed by every FIs, carriers, and administrative contractors (MACs).

https://www.aace.com/files/cms-nlcd-for-common-endocrine-procedures-2012.pdf