➡️ Scope year - 2023, 2024
Inside the scope - process the chart
Outside the scope - skip the chart
➡️Formats of the charts
1.SOAP 2. CHEDDAR
Subject Chief complaints
Objective HPI
Assessment Examination
Plan Diagnosis / Drug list
Diagnosis / Treatment
Assessment
Referral
➡️ Elements of charts
* CC [chief complaints]
* HPI [history of present illness]
* Subject
*Objective
* PMH [past medical history]
*PL [problem list]
* Family history
* Social history
* Medication list
* Surgical list
*ROS [review of system]
* Physical examination
* Assessment
* Plan
* Signature
➡️ Identifiers
>> Primary
* patient name
* DOB
* Sex
>> Secondary
* MRN no: [member registration no]
* Insurance no:
* SSN no: [social security no]
* Telephone no:
➡️ Things need to be validated before validating the chart
* Check the patient name and DOB
* Check if the DOB is missing
* Check the scope of the year
* Check the chart is having proper face to face evidence
* Check it is signed by a valid provider or not
* Check the chart is having proper DOS or not
➡️ Proper face to face evidence that is physical examination is present - process the chart
➡️ In the absence of physical examination - we have to check the verbiage evidences;
* Patient seen today
* Saw today
* I have meet the patient today
* I was conversing with the patient today
* I met him today
* I saw her today
➡️ When we will code the chart
* Correct patient name and DOB matches in tool and chart
* Falls under the scope year
* Valid face to face evidence
* Contains all the element
* Continuity of the chart
* Valid signature
➡️ When we will not code the chart
* Incorrect DOB
* Incorrect patient name
* Incorrect sex
* Incorrect secondary patient identifier [ SSN no:, MRN no:, telephone no:, insurance no:]
* Missing face to face evidence
* Chart contains only invalid document [invalid provider]
* Charts contains documents only signed by invalid provider
Eg : MA, RN, MBBS
* Chart contains only scanning issues [blurred charts]
* Ill eligible document [not understandable]
Eg : Scribbled document, Handwritten
* Out of the scope year
* Chart only contains patient details [pt personal details]
Eg : Family details, Friends details, Insurance details, Gas bills, Rental agreement, Fax etc
* Chart contains only reports
Eg : X-ray, Scopy, ECG
* Supper bills [insurance payment details]
* Missing pages
* Missing provider credential
➡️ DOS concept
other names of DOS
* Encounter date
* Note date
* Service date
* Progress note date
* Date or service
* Note validated date
* Note processed date
* Consult date
* Evaluated date
➡️ Sign date concept
* same day
* 1 or 2 days after
* 1 week after
* But it should be inside 180 days.
* After 180 days it will not consider as a valid - Then skip the chart
➡️ Medication list - other names
* Drug list
* medlist
* Outpatient medications
* Inpatient medications [hospital stay]
>> 1: many concept - we can take one drug for different conditions
Eg : metoprolol - uses both HTN and HF
➡️ MEAT ➡️ TAMPER
Monitor Treatment
Evaluation Assessment
Assessment Monitor
Treatment Plan
Evaluation
Reference
* MEAT & TAMPER is used to take the code
➡️ Things that can be consider it as a TAMPER
* Referal
* Followup
* Labs
* Consultation
* Advice
* Rejection of the treatment prescribed by the provider by the patient
* Drug or medication
* Scopy
* Therapy [chemotherapy, radiotherapy, immunotherapy]
* Surgery
* Amputation
* Placement of artificial devices
Eg : pacemaker, stent
* Transplant
* Artificial opening [ostomy]
* Palliative care [coma pt, bedridden pt]
* Inpatient treatment [more than 24 hours stay]
* Diet instructions
Eg : DM patients, morbid obesity patients
* Increase / decrease of drugs
Eg : DM [insulin level will decrease / increase]
* Lab reference
* Care
➡️ Active headers
* HPI - history of present illness
* Subject - provider active voice
* Physical examination
* Assessment
* Plan
* Objective
➡️ Inactive headers
* PMH
* Problem list
* Social list
* Family list
* Surgical history
* DOS
* Medication list
➡️ Acute and Chronic
>>>Acute
* Temporary
* Severe
* Need immediate care
* Inpatient
* Need strong tamper
* Admit reason must be the same dx [assessment, treatment]
>>> chronic
* Life long
Eg : DM
* Outpatient / inpatient
* Basic Tamper / one word meat [stable, controlled]
* Can code with other dx [combination code]
<<< For acute condition/critical condition - strong TAMPER is need, if it is either active/inactive header
➡️ Chronic and Nonchronic
>>> Chronic
* Not curable
* Life long
* One word meat
* More severe
>>> Non chronic
* Either curable / Non curable
* Temporary
* One word meat
* Less severe
<<< In active headers - chronic / non chronic condition - we can take code directly without TAMPER
<<< Inactive headers - chronic / non chronic condition - need to check MEAT / TAMPER
➡️ Insulin status code
* DM type 2 only. For type 1 no insulin code
* Insulin brand name
* 2 codes - DM & insulin
➡️ Defualt - DM type 2
