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Chapter 11 Medical Documentation 221
On the other hand, if charting is inaccurate, incomplete, or improperly done, it can raise questions about
what actually happened. This might cause a health
care provider to lose a malpractice suit. Always
remember, if it’s not documented, it didn’t happen.
Any communication with a patient should be accurately recorded.
Proper Use of Abbreviations
inCharting
It’s common to see abbreviations in charting entries.
Using them saves writing time and space. Your ofce
should have a list of standard abbreviations. Table 11-1
shows some abbreviations that are used commonly in
charting.
Be careful how you use abbreviations. Errors in
patient care could result if you use a wrong abbreviation, or one that has an unclear meaning, in the chart.
Also, always use the standard abbreviations instead
of making up your own. Remember, following these
procedures is vital because the medical record is a legal
document.
Study Skill
Sometimes, nding the right time to study is the
biggest obstacle you will encounter. A great way to
insure that you have time to devote to your studies is to schedule it into your day. Consider scheduling 30 minutes to an hour each day as devoted
school work time. Make sure you share with family
and friends the time you select so they know you
are unavailable during that time. Utilize this time
to review your notes, study for exams, and work on
assignments. At rst, it might be a challenge to hold
yourself to the new schedule; however, once you get
into the routine, it seems completely normal.
Phone Calls
Any phone calls made to or about patients must be
recorded in their individual records. Calls include the
following:
Pharmacy calls for new prescriptions or rells. It is
r
important to chart the name of the medication, dosage, directions, quantity, and last rell.
Table 11-1
Abbreviation Meaning
a
Abd Abdomen
ant. Anterior
AP Anteroposterior
Apt Appointment
Ax Axillary
b.i.d. Twice a day
BP Blood pressure
c
CC Chief complaint
c/o Complains of
CPE, CPX Complete physical exam
Cx Cancelled
D/C Discontinue
F Fahrenheit
Fx Fracture
h.s. Bedtime (hour of sleep)
Hx History
L Left
LLE Left lower extremity
LLQ Left lower quadrant
LUE Left upper extremity
Abbreviations Used in Charting
Before
With
Abbreviation Meaning
NKDA No known drug allergies
noct. Nocturnal
p
p.c. After a meal
PE Physical examination
p.r.n. As needed
pt. Patient
q.i.d. Four times a day
R Right
R/O Rule out
RLE Right lower extremity
RLQ Right lower quadrant
RUE Right upper extremity
RUQ Right upper quadrant
R/S Rescheduled
s
SOB Shortness of breath
Spec Specimen
s/p After (status post)
STAT Immediately
t.i.d. Three times a day
TPR Temperature, pulse, respiration
After
Without
LUQ Left upper quadrant
222 Section III Administrative Medical Assistant Skills
Laboratory results from the lab to the physician or
r
recommendations from the physician to the patient.
Be sure to note core values along with the patient
results. Also note any questions or concerns the
patient may have.
Timely Charting
As you already know, information in the patient
record is recorded in chronological order. The most
recent entries should always be first. This is one reason why you should record contacts with patients
soon after they take place. Another reason is the
events will still be fresh in your mind. The EMR system automatically date and time stamps all entries. If
you wait, someone might write another, later event in
the record. Also, you might forget the details of the
encounter.
Charting Communications
fromPatients
Phone calls from patients are usually charted in narra-
tive style
speak. Document the conversation immediately. Include
the following information in your note:
What the patient requested or said
r
What you said and the actions you took
r
in the chart. Any replies to the patient should only occur
using the portal. This will insure the communication is
entered into the medical record.
, meaning that it is written out as you would
E-mails from patients should be electronically entered
Inactive records
r
Closed records
r
Active Records
Active records are the records of patients who have
been seen recently or within the past 3 years.
Inactive Records
Inactive records are the records of patients who have
not been seen in 3 or more years. Such patients have
not terminated their care nor has their care been terminated so they are welcome to return to see the physician at any point. However, patients who have not
been seen in 3 or more years are considered to be new
patients.
Closed Records
Closed records are the charts of patients who have
ended their relationship with the physician. Here are
the main reasons you would classify a patient’s chart
as closed:
The patient has moved away.
r
The physician–patient relationship has been termi-
r
nated by letter.
The patient has elected to change providers
r
The patient has died.
r
Closed records should be removed from active les
and archived in the system.
Record Retention
C
O
G
Good management of an ofce’s electronic medical
records requires ve basic things.
1. Properly and accurately create the records for new
2. Scan new items in patients’ records accurately and in
3. Properly and accurately enter information regarding
4. Maintain the security and condentiality of
5. Utilize a secure method of backing up all records.
MANAGING MEDICAL
RECORDS
patients.
a timely manner.
care.
records.
Classications of Medical Records
Patients’ records are classied into three categories:
Active records
r
All patient records should be kept permanently, but they
don’t all have to be kept in the active system. Closed
records can be archived within the system. All patient
records should be easily accessible. This will allow for
access either should the need arise to provide information to aid in the patient’s care or should it be needed
for legal reasons.
EMR and Ethical Responsibility
A well-known celebrity comes to your ofce for
visit. During the visit, you assist in the care of the
patient. You review the patient’s current illness,
past medical, social, and family history. As with
any patient, this information is condential and
privileged and thus can’t be shared with anyone.
Even the mention that this person was seen in the
ofce is a breach. Care must be taken to insure
that you never release any information, knowingly
or unknowingly, about any patient.
C
O
G
The two main systems used to le and retrieve medical
records are as follows:
r
r
to search for records using either the numeric record
number or the patient’s name.
FILING SYSTEMS
Alphabetical ling system
Numeric (number) ling systems
Most EMR systems utilize both systems allowing you
Alphabetic Filing
This method of organizing medical records places
them in alphabetical order by patients’ last names. If
two or more patients have the same last name, the system orders them alphabetically by their rst names,
and so on.
Numeric Filing
Numeric ling systems usually assign a six-digit num-
ber to each patient also referred to as a medical record
number (MRN). Utilizing an MRN in communication can be more secure and accurate. It eliminates the
need to say the patient’s name and reduces the risk of
misspelling.
Numeric systems have a couple of advantages over
the alphabetical system:
It makes no difference if two or more patients have
r
the same name, such as John Smith. Each John Smith
will be assigned a different MRN. Helping to reduce
the risk of entering information into the wrong
record.
The results of tests for HIV and AIDS are strictly con-
r
dential. Use numbers instead of names to identify
the test record of patients to add privacy. This feature
has helped make numeric ling systems more popular
in laboratory environments.
Chapter 11 Medical Documentation 223
Cultural Connection
There are some specic populations that are at higher
risk for HIV. The CDC reports that young black males,
aged 13 to 24, engaging in sexual activity with other
males demonstrated the highest occurrence of new
cases in 2010. Many ofces now include questions
on their social history forms regarding sexual activity. This information is both private and condential.
You may be called upon to provide patient education
to individuals at risk for HIV or other sexually transmitted illnesses. Regardless of your personal opinion
or views, you must present information professionally and without bias.
Other Filing Systems
Your ofce will have more les than just patient charts.
Some examples of other records include the following:
Employee personnel les
r
Inventories of equipment and supplies
r
Records of past supply orders
r
Accounts payable
r
Insurance records
r
Catalogs from suppliers
r
Your ofce will likely use a system of subject l-
ing
for keeping such records. This is a system in which
records are grouped alphabetically according to their
subject—insurance, medications, referrals, and so on.
Here are some other ling systems you might see or use.
Geographic ling—documents are grouped alpha-
r
betically according to location, such as state, county,
or city. This method is often used in case studies or
research projects.
Chronological ling—documents are grouped in the
r
order of their date, such as year or month. This system is frequently used for accounts payable.
Preparing for Externship
You should approach your externship just as if you are
an actual employee of the medical ofce. Your actions
should reect everything that an employer would
expect from any employee. Show up for work on time
and give your all each day. Some students adopt the
attitude that since they are not receiving pay for this
experience, they don’t have to apply much effort. Not
true. This time above all else is your opportunity to
shine and show everyone what a great employee you
can be. Your professional behavior will be evaluated
by the extern site preceptor. You are not expected to
be perfect; however, you need to have an attitude of
willingness. You need to be willing to accept all tasks
assigned even though you may not like all of them.
At the beginning of the externship, most sites assign
students basic tasks to help them get acclimated to
the site. You will probably shadow another employee
the rst few days so you can get familiar with the
ow of the ofce. Do not get discouraged thinking
that this is all you will be doing. Many ofces are just
trying to see how you handle the smaller basic tasks
before they assign more responsibilities.
224 Section III Administrative Medical Assistant Skills
Chapter Recap
● Medical records are legal documents that should be
complete and accurate.
● All encounters with a patient are documented in their
record.
● Security of all patient health information should be
a top priority.
● Patient records can be organized using POMR or
SOMR format.
● There are three types of patient records: active,
inactive, and closed.
Online Resources for Students
Resources for students available on thepoint.
lww.com include the following:
● Audio Glossary
● Animations
Exercises and Activities
● All records should be backed up to a secure location.
● There are two main types of ling systems for medical
records: alphabetic and numeric.
● Other les in the ofce that require ling include
employee records, payroll, purchasing invoices, and
insurance records.
● Geographic ling systems are frequently used for
research.
● Accounts payable are organized using a chronological
ling system.
● Competency Evaluation Forms
● Harris CareTracker Case Studies
● Interactive Games & Activities
● Certication Preparation Question Bank
● Videos
Certication Preparation Questions
1. Which of the following demonstrates a medical
record security practice?
a. Leaving a medical record open for the patient to
view, as it is their record
b. Turning off the computer screen when walking
away from the system
c. Pressing the window and “L” key to lock the
system
d. Allowing another medical assistant to use your
password when they forget theirs
e. Sharing the names of famous athletes that come
to your ofce to help build the practice
2. Which of the following individuals meets the
“meaningful use” standard for entering laboratory
orders into patient records?
a. Any employee working in the ofce
b. Only employees in the laboratory
c. Only the physician
d. Credentialed medical assistants (RMA or CMA)
e. Any medical assistant in the ofce
3. Personal information, in a medical record, includes
which of the following?
a. Social Security Number
b. Chief complaint
c. History of present illness
d. Social history
e. Laboratory results
4. Medical records organized by department or
source of information is referred to as:
a. source-organized medical record.
b. problem-organized medical records.
c. departmentalized medical records.
d. source-oriented medical records.
e. problem-oriented medical records.
5. Information that can be obtained only from the
patient would be recorded under:
a. plan.
b. subjective.
c. assessment.
d. objective.
e. treatment.
Chapter 11 Medical Documentation 225
6. When documenting in the medical record,
information observed by the physician or medical
assistant should be entered as:
a. plan.
b. subjective.
c. assessment.
d. objective.
e. treatment.
7. If a patient smokes 3 packs of cigarettes a day,
where would you note this in the medical record?
a. Past medical history
b. History of present illness
c. Family history
d. Surgical history
e. Social history
8. The medical records of a deceased patient would
be classied as what type of record?
a. Inactive
b. Closed
c. Active
d. Deactivated
e. Dead
9. If les are stored by the medical record number
(MRN), what type of “ling” system would this be
referred to as?
a. Numeric
b. Alphabetical
c. Geographic
d. Subject
e. Chronological
10. If ling records or reports based on the location or
region of occurrence this would be referred to as
what type of ling system?
a. Numeric
b. Alphabetic
c. Geographic
d. Subject
e. Chronological
P
S
Y
CareTracker Connection
Patient Medical Records
and Documentation
CareTracker Activities Related to
This Chapter
Case Study 2: Entering Patient Demographic and
r
Insurance Information
Managing patients’ medical records is a critical responsibility of the medical assistant. An electronic medical
record system, such as CareTracker, makes performing
this task much easier and more efcient.
Tasks discussed in this chapter that can be performed
in CareTracker include the following:
Creating patient medical records
r
Documenting patient personal information
r
Documenting the following patient clinical informa tion:
r
Chief complaint
History of present illness
Medical history
Review of systems
Laboratory results
Diagnosis or medical impression
Treatment plan
Progress notes
Medication administration
Patient education
Documenting workers’ compensation cases
r
Documenting communication with patients
r
Managing patient medical records
r
Many of these tasks are discussed in CareTracker
Connection features in other chapters. A task we’ll consider here is entering patient demographic and insurance
information.
If a patient is new to a medical practice, one of the
rst responsibilities you’ll have is to gather the patient’s
personal information. This includes name, home and
billing addresses, phone number(s), e-mail address, date
of birth, Social Security Number, gender, and marital
status.
226 Section III Administrative Medical Assistant Skills
To ensure proper billing and payment, it is also
imperative to collect the patient’s insurance information, if applicable, including the name and address of the
If the patient is employed, you must also collect
employment information, including the name and
address of the employer, occupation, start and end dates,
and work phone number and e-mail.
In addition to gathering this data initially, it is also
your responsibility to regularly check in with the patient
regarding any changes in this information and to update
the medical record accordingly. You’ll get a chance to
practice this task in Case Study 2: Entering Patient
Demographic and Insurance Information.
To access Case Study 2, go to http://thepoint.lww.com,
log in using your username and password, search for The
Complete Medical Assistant, click on “Student Resources,”
insurance company; name of the plan; subscriber, group,
and member numbers; eligibility from and to dates; and
copayment amount.
nd the Harris CareTracker materials, and click on “Case
Study 2.”
Culture Connection Resource
http://www.cdc.gov/nchhstp/newsroom/docs/
HIVFactSheets/TodaysEpidemic-508.pdf
http://www.cdc.gov/nchhstp/newsroom/docs/
HIVFactSheets/TodaysEpidemic-508.pdf
Medical Insurance
12
Coding
Chapter Objectives
● Explain what coding is and why it is used.
● Describe the relationship between diagnostic coding,
procedural coding, and reimbursement.
● Describe how the ICD-10-CM is organized.
● List the steps in identifying a proper diagnostic
code.
● Name the common errors in diagnostic coding.
● Perform diagnostic coding.
● Describe how the CPT-4 is organized and used.
● Summarize the factors that determine which E/M
code to assign a patient visit.
● Understand HCPCS codes and surgical packages.
● Perform procedural coding.
● Demonstrate understanding of upcoding and
downcoding.
● Determine medical necessity as it applies to
coding.
● Understand the importance of communication
with medical providers to ensure accurate code
selection.
CAAHEP & ABHES Competencies
CAAHEP
● Describe how to use the most current procedural
coding system.
● Describe how to use the most current diagnostic
coding classication system.
● Describe how to use the most current HCPCS level II
coding system.
● Discuss the effects of upcoding and downcoding.
● Dene medical necessity as it applies to procedural
and diagnostic coding.
● Perform procedural coding.
● Perform diagnostic coding.
● Utilize medical necessity guidelines.
● Utilize tactful communication skills with
medicalproviders to ensure accurate code
selection.
ABHES
● Perform diagnostic and procedural coding.
227
228 Section III Administrative Medical Assistant Skills
Chapter Terms
Alphanumeric
Bundled
Comorbidity
Diagnostic codes
Downcoding
Etiology
Global surgical follow-up
Initial encounter
Key components
Late effects
Abbreviations
CMS
CPT-4
E/M
Case Study
Jessica McNeil’s mother brought her to the ofce
today for her prekindergarten physical examina-
tion. During her visit, the doctor ordered two immu-
HCPCS
HIPAA
Medical necessity
Modiers
Physical status modier
Procedure codes
Primary diagnosis
ICD-10-CM
NCHS
nizations (DPT and IPV) and a hemoglobin test that
you performed. As the medical assistant, you need
to complete the coding information.
Subsequent encounter
Sequela
Unbundled
Unbundling
Upcoding
OIG
WHO
Medical coding is the translation of a written diagnosis or procedure into an alphanumeric code, the use of
numbers and letters. This process can be a complex task,
as it requires accuracy, medical knowledge, and careful
attention to detail.
Coding is one of the most important jobs you may
do as medical assistant. The codes you use to describe
a patient’s diagnosis and treatment will determine what
the patient’s health insurance plan will pay. If the codes
you assign are incorrect or incomplete, there may be a
reduction, delay, or denial of the payment amount to
the provider. Since most of a medical ofce’s income
generally comes from insurance, proper coding is critical. The information in this chapter will introduce
you to the process of billing services rendered to the
patient and coding them for submission to the insurance company.
C
O
G
Medical coding replaces verbal descriptions of diseases,
injuries, conditions, and services with alphanumeric
codes, those made up of letters and numbers. These codes
make medical information more standard, or uniform,
than written descriptions. Medicare, Medicaid, and
other health care plans require providers to use them.
MEDICAL CODING
HIPAA, Health Insurance Portability and Accountability
Act, requires the use of ICD codes when processing
insurance claims. There are two types of codes:
Diagnostic codes—These codes are used to iden-
r
tify the reason the patient is seeking care. These
codes come from the International Classication of
Diseases, Tenth Revision, Clinical Modication, ICD-
10-CM. This book has recently undergone a major
update allowing more detail when assigning codes.
Procedure codes—These codes describe services pro-
r
vided to the patient. Most services are located in the
fourth edition of Current Procedural Terminology
(CPT-4); however, some codes are in the HCPCS
book. The Healthcare Common Procedure Coding
System (HCPCS) book is used to code for supplies
and/or services not listed in the CPT book. HCPCS
codes are important, yet frequently forgotten, codes.
Case Questions
A
F
F
patient’s mother? What would you say if the
mother became angry?
If you discover that the insurance company does not reimburse for the hemoglobin test, how would you inform the
Chapter 12 Medical Insurance Coding 229
For example, when giving an injection, the code for
the administration of the injection is located in the
CPT book; however, this does not include the medication. The medication code is listed in the HCPCS
book.
There are many benets of coding, such as:
Ensuring that all health care providers report the
r
same conditions and procedures in exactly the same
way.
Collecting accurate of health information and
r
statistics.
Performing medical reviews or medical chart audits
r
is easier. Medical chart audits can occur both in the
physician’s ofce and at the insurance company. The
charts are reviewed for accuracy and appropriateness
of codes used for claims.
Efcient, accurate processing of health insurance
r
claims.
Coding and Insurance
All codes you use for patient billing must be complete
and correct. The CPT codes reported on a patient’s
insurance claim form determine the amount insurance
will pay for the service rendered. ICD codes help determine
medical necessity. This means the procedure or
service billed was reasonable for the patient’s medical
condition.
For example, an insurance company wouldn’t consider a chest x-ray medically necessary if the ICD code
was for an ear infection, but if the diagnostic code
was acute bronchitis, the insurance company probably
would pay. The diagnosis code justies the procedure
code. On the other hand, inaccurate coding can lead to:
Delayed payment
r
Reduced payment
r
Denied payment
r
Of course, there must be documentation in the
patient’s chart to support the diagnoses and procedures
used. Upcoding is assigning a code for services greater
than the service provided to the patient. Upcoding is
an unethical and illegal practice.
be the opposite, it represents coding for less than the
actual service provided. This practice would then result
in underpayment to the physician. Proper coding is critical to your ofce reimbursement.
Downcoding, would
Diagnostic Coding
The ICD is a system of classifying diseases developed
by the World Health Organization (WHO) in the 1930s
and 1940s. In 1948, the rst ICD book was published.
Since then, the list has been revised ten times. The latest
revision, the ICD-10, has recently been adapted for use
in United States. The ICD-10-CM was published in the
United States in 2015. It is updated each year with codes
added, changed, and sometimes removed. The National
Center for Health Statistics (NCHS), a US government
agency, keeps the list of diagnoses current. The WHO
approves all changes before they are published. Changes
generally are published each October. Most health plans
that require claims to be submitted after January 1 use
the latest version of the codes.
ICD-10-CM code books are available from several
publishers. Each publisher’s book presents the information a little differently but the content is the same.
Publishers also sell the annual updates to the ICD10-CM. Your ofce should use the updates from the
same publisher as your coding book.
ICD-10-CM Code Book
The ICD-10-CM is issued in two separate books, ICD10-CM and ICD-10-PCS. The ICD-10-CM is divided
into two volumes:
Volume 1: Tabular List of Diseases—This section pro-
r
vides a numeric listing of codes. This section contains
greater detail and is used second to the alphabetic
index to insure the proper code is being assigned.
Volume 2: Alphabetic Index of Diseases—As the
r
name suggests, codes are listed alphabetically. This
section is used rst to obtain the numeric code and
then is veried as the best code using Volume 1.
The ICD-10-PCS contains only Volume 3: Tabular
List and Alphabetic Index of Procedures. This book
includes codes for hospital procedures.
Symbols and Conventions
Prior to using the ICD-10 books, it is important to
become familiar with the symbols and conventions used
within each book. This information is found in the forward section of the book, the section immediately following the index. Some of the more commonly used
symbols are also listed at the bottom of each coding
page in Volume 2. A summary of all the symbols are
located at the bottom of each page in Volume 1. For
example, a red dot acts like a stop sign to alert you that
the code requires additional digits. This is of signicant
importance as the more detailed the diagnose code is, the
more accurately the claim can be processed. If digits are
omitted from the claim, it will likely be rejected, resulting in a delay of payment. Pay special attention to the
instructional notations at the beginning of each chapter. These notations will provide you with information
regarding inclusions and exclusions within the chapter
along with guidelines for seventh character placement.
Table 12-1 provides a few examples of the coding conventions found in the ICD-10-CM.
230 Section III Administrative Medical Assistant Skills
Table 12-1
ICD-10-CM Coding
Conventions
code rst
use additional
Code also
N Newborn
Instructions indicating the underlying
condition that should be coded rst
Indicates another code may be
required
Instructs that two codes are
likely needed to fully explain the
condition
Organization of Codes
Volume 1 organizes diseases and other conditions into
21 chapters, according to
ease, or body system. The diseases are alphanumerically
listed in sequence within each chapter and throughout
the book beginning with A and ending with Z, excluding
the letter U.
Special Codes
The V through Y codes are used to code conditions
related to external causes. For example, if a person is
injured due to a fall from non-in-line roller skates, the
initial code would be V00.121. This code requires an
additional character to indicate if this was the
encounter
sequent encounter
, the rst time seeing the patient. If it is a sub-
or sequela, this indicates follow-up
encounters. For example, if it is the initial encounter, the
code used would be V00.121A. The A represents the initial encounter. Table 12-2 represents examples of codes
used in External Causes. Take some time to explore the
External Causes section of the ICD-10-CM coding manual to become familiar with the diagnoses covered in the
section. Remember, these codes are in addition to the
descriptive injury code.
The Z codes are used when a patient seeks care but
is not ill or injured. These codes are used when a patient
is not currently ill but is seeking care. A few types of
care that the Z codes are used for include physicals, well
examinations, and normal pregnancy.
Table 12-2
Examples of External Causes
from ICD-10-CM
X ● W27.1 Contact with a garden tool
Contact with: hoe, non powered lawnmower, pitch-
fork, or rake
●
X
W32 Accidental handgun discharge
●
X
indicates the need for a place holder (X) and addi-
tional characters
etiology, the cause of the dis-
initial
Case Question
A
F
F
tions. The diagnosis codes for her visit will be
Z codes; annual physical examination of a child
age 5 and vaccination against DPV and IPV.
Using the ICD-10-CM coding manual, what are
the correct diagnosis codes for her visit?
Recall from the case study that Jessica
McNeil came to the ofce for her prekindergarten physical and immuniza-
Coding Diagnoses
Diagnostic codes can range from three to seven characters in length. The more characters used within the
code, the more detail is translated in the code. The ICD10-CM coding manual is organized by chapters, according to the etiology (cause of the disease) or body system.
Each section, within the chapter, has a three-character
code that identies the category. Additional characters
are used to provide more detail about the condition, up
to a total of seven characters. There will be times when
you need a seventh digit but not a sixth. In these cases,
you will use an X as a placeholder. This is extremely
important as a change in the position of a number
within a code changes its meaning. You should pay close
attention to the symbols that indicate if additional characters are required. In cases where additional characters
are required, there will be a box at the beginning of the
section that contains the additional characters. You need
to verify your code fails within those listed for the additional character box you are using. Some chapters have
multiple boxes so you should use care to insure you are
in the correct area.
Alphabetic Index to Diseases
and Injuries
You should always begin the coding of a diagnosis in
this section. This section allows you to look up the diagnosis alphabetically. Once you have selected a code from
this section you will then use that code to look in the
tabular list of diseases and injuries. As previously mentioned, this section provides more detail for the chosen
codes. At times, you will nd that the code you found
in the alphabetic index may not be the best code for
the diagnosis. Utilizing this practice every time you code
will insure that you’re coding to the greatest possible
level of detail.
Table of Neoplasms
This section of the ICD-10 lists codes for neoplasms by
anatomical site. You will need to know if the neoplasm is
malignant, benign, or uncertain behavior. When dealing