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Abstracting-Coding

Records
Yvette Pawlowski
Spring 2015

Table of Contents

Types of Coding ............................................................................................................................................. 2


Diagnostic Coding ..................................................................................................................................... 2
Procedural Coding ..................................................................................................................................... 2
What Code Sets Do I Use To Code This Type Of Record? ............................................................................. 2
Who Am I When I Code This Type Of Record?.............................................................................................. 3
Abstracting/Coding Records ......................................................................................................................... 3
Step-by-Step Method of Abstracting/Coding Records ............................................................................. 3
Step A: Review Face Sheet or Registration Record or Encounter Form ............................................... 3
Step B: Review History and Physical, Emergency Department Report, and/or Consultants Report ... 4
Step C: Review Operative Reports, Special Procedure Reports, and/or Pathology Reports ................ 5
Step D: Review Physicians Progress Notes .......................................................................................... 6
Step E: Review Laboratory, Radiology, and/or Special Test Reports .................................................... 6
Step F: Review Physicians Orders ........................................................................................................ 6
Step G: Review Medication Administration Record ............................................................................. 7
Step H: Review Discharge Summary ..................................................................................................... 7
Step I: Query Physician......................................................................................................................... 7
Step J: Assign and Sequence Codes ...................................................................................................... 7
Additional Tips ...................................................................................................................................... 9
Types of Records ........................................................................................................................................... 9
Format of Records................................................................................................................................. 9
Physician Office Records ....................................................................................................................... 9
Ambulatory (Outpatient) Surgery Records ......................................................................................... 10
Emergency Department Records ........................................................................................................ 10
Outpatient Services Records ............................................................................................................... 10
Inpatient Records ................................................................................................................................ 11
AHIMA Guidelines for Inpatient Coding...................................................................................................... 12
Code .................................................................................................................................................... 12
Do Not Code or Assign ........................................................................................................................ 13
Coding/Abstract Summary Form ................................................................................................................ 14
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Types of Coding
Diagnostic Coding

Translating healthcare diagnoses/diagnostic statements into code to establish medical


necessity using the following code sets:

ICD-9-CM, Volume 1 and 2International Classification of Diseases, Ninth


Revision, Clinical Modification
ICD-10-CM, Volume 1 and 2 International Classification of Diseases, Tenth
Revision, Clinical Modification

Procedural Coding
Translating healthcare procedures (services and treatments) into code using any of the
following code sets:

CPTCurrent Procedural Terminology


HCPCSHealthcare Common Procedure Coding System, Level II
ICD-9-CM, Volume 3International Classification of Diseases, Ninth Revision,
Clinical Modification, Volume 3
ICD-10-PCS International Classification of Diseases, Tenth Revision,
Procedural Coding System

RECORD
TYPE

What Code Sets Do I Use To Code This Type Of Record?


ICD-9-CM/ICD-10-CM
CPT/HCPCS
ICD-9-CM (vol 3)
Diagnosis Codes
Procedure Codes
procedure codes;
ICD-10-PCS
Yes
Yes
NO

Physician
Office
Ambulatory
Yes
(Outpatient)
Surgery
Emergency
Yes
Room
Inpatient
Yes
(hospital coder)

Yes

NO

Yes

NO

NO

Yes

Physician
Office

Ambulatory
(Outpatient)
Surgery

Emergency
Room

Inpatient

Who Am I When I Code This Type Of Record?


When coding these records, you are the physician office coder,
which means you are coding for the physicians office any
treatment/procedures and evaluation/management that was done at
that office during that visit with CPT and/or HCPCS codes, and why
these were done (diagnoses) using ICD-9-CM or ICD-10-C codes.
When coding these records, you are the ambulatory surgery facility
coder, which means you are coding for the facility what
procedure(s) were done, including any preoperative testing, using
CPT and/or HCPCS codes, and why this procedure was done
(diagnoses) using ICD-9-CM or ICD-10-CM codes.
When coding these records, you are the emergency department
coder, which means you are coding for the ER what
treatment/procedures and evaluation/management was done using
CPT and/or HCPCS codes, and why these were done (diagnoses)
using ICD-9-CM or ICD-10-CM codes.
When coding these records, you are the hospital coder, which
means you are coding for the hospital in order to assign the
DRG. This means you will be coding the diagnoses and major
procedures for this case using ICD-9-CM/ICD-10-CM codes for
diagnoses and using ICD-9-CM Volume 3 or ICD-10-PCS codes for
the major procedures. See the section below on pages 4 and 5
detailing what code ranges of ICD-9-CM Volume 3 that are not
considered major procedures. You are NOT the physician biller,
which means you are not coding the E/M services for these
records. This is done by the physician billing office or the
individual physicians office. You are also not the laboratory or
ancillary services biller, and are not coding for any CPT coded
services.

Abstracting/Coding Records
Step-by-Step Method of Abstracting/Coding Records

Step A: Review Face Sheet or Registration Record or Encounter Form

Inpatient Records or Facility Records (Outpatient Encounters such as ER,


Radiology, Labs, or Ambulatory Surgery) will have a Face Sheet or Registration
Record. Physician Office Records may have an Encounter Form as well.

The Face Sheet or Registration Record is the front page of the medical record. It
contains basic patient identification data, insurance information, and sometimes
clinical data such as the admitting and final diagnoses.
What to look for:
a. Length of stay (dates of treatment, admission date, discharge date), sex,
age, and admitting diagnosisall of which can impact the complexity or
assignment of the diagnosis
b. Prospective payment system payers (e.g., Medicare or Medicaid), which
may raise compliance and reimbursement issues

Step B: Review History and Physical, Emergency Department Report, and/or Consultants
Report

Inpatient Records or Ambulatory Surgery will have a History and Physical, which
is generated by the attending physician. It contains the chief complaint (CC) of
the patient, history of the present illness (HPI), review of systems (ROS), and
personal, family, and social history (PFSH). This contains subjective data
collected from the patient to begin the process of diagnosis by the physician. The
physical examination (PE) includes a system-by-system physical examination by
the provider to collect objective data on the patients condition.
o Review the H&P to determine the chief reason(s) for admission and to
begin to get a feel for the possible options for the principal diagnosis (i.e.,
the condition, after study, chiefly responsible for occasioning the
admission of the patient to the hospital for care) and secondary
diagnoses. Review the history for secondary diagnoses such as
comorbidities and other diagnoses affecting patient care that need to be
reported per Uniform Hospital Discharge Data Set (UHDDS) rules. Note
that UHDDS rules are included in the ICD-9-CM and ICD-10-CM Official
Coding Guidelines under Sections II, III and IV, and Appendix I. Note, the
UHDDS definition of principal diagnosis applies only to inpatients in
acute, short-term, long-term care and psychiatric hospitals.
o Review the physical examination for abnormal findings.
UHDDS Rules (Definitions): The UHDDS definitions are used by acute care
hospitals to report inpatient data elements in a standardized manner. The
UHDDS data elements used in the DRG classification system are described
below. Proper DRG assignment and resulting reimbursement is dependent on
reporting these elements correctly.
o Diagnoses: All diagnoses that affect the current hospital stay are to be
reported.

o Principal diagnosis is defined as "that condition established after study to


be chiefly responsible for occasioning the admission of the patient to the
hospital for care."
o Other (Additional) diagnoses are defined as "all conditions that coexist at
the time of admission, that develop subsequently, or that affect the
treatment received and/or the length of stay."
o Diagnoses that are related to an earlier episode of care, which have no
bearing on the current hospital stay, are to be excluded. For reporting
purposes the definition for 'other diagnoses' is interpreted as additional
conditions that affect patient care in terms of requiring clinical evaluation;
therapeutic treatment; diagnostic procedures; extended length of hospital
stay; or increased nursing care and/or monitoring.
o Procedures: All significant procedures are to be reported. Significant
procedures are those that are surgical in nature; carry a procedural risk;
carry an anesthetic risk; or require specialized training.
o The principal procedure is one that was performed for definitive treatment
rather than one performed for diagnostic or exploratory purposes, or was
necessary to take care of a complication. If there appear to be two
procedures that meet the above definition, then the one most related to
the principal diagnosis should be selected as the principal procedure.
Determine the provisional or tentative diagnoses given by the physician and plan
for care. The Emergency Room or Emergency Department Report provides initial
diagnosis and treatment information by the emergency room physician.
Physician Office records will contain physician notes. Review physician notes for
key words that indicate diagnostic statements and procedural statements.
A Consultants Report contains an expert opinion requested by the attending
physician to aid in the diagnosis and treatment of the patient. Note what the chief
reason was for the consultation request by the attending physician, and note all
diagnoses given by the consulting physician.
o It is helpful to think of these reports as a connected set; that is, each
report that comes from a different physician serves a similar function,
which is to assess the patient and begin a plan of care. Often, coders
forget to review an emergency room record that may in fact have more
detail than the attending physicians H&P.

Step C: Review Operative Reports, Special Procedure Reports, and/or Pathology Reports

If applicable, go to the operative or procedure report to note operations and/or


procedures and the preoperative and postoperative diagnoses. Depending on
whether it is a major operation or a minor procedure, note that medical record
forms related to operations or special procedures usually exist as a set of linked
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forms. This operative set includes the operative report itself, the anesthesia
record, special consents for surgery, the recovery room record, and pathology
reports for specimen analysis.
o Note the results of special procedures such as cardiac catheterizations,
colonoscopies (lower endoscopies), esophagogastroduodenoscopies
(upper endoscopies), and bronchoscopies, with or without biopsies.
o Remember to sequence definitive before diagnostic procedure codes per
UHDDS rules.
o Note pathologic diagnoses given for any specimens removed at operation
that are usually dictated by the pathologist.
Step D: Review Physicians Progress Notes

Physicians progress notes are written as often as the patients condition


warrants. Progress notes include an admit note, notes that relate to the patients
condition and progress, complications, response to treatment, and a discharge
note. Review physicians progress notes for significant diagnoses, findings, and
resolution of problems or complications.

Step E: Review Laboratory, Radiology, and/or Special Test Reports

Laboratory work includes several types of chemistry tests, analyses, cultures,


and other examinations of body fluids or substances such as blood, urine, stool,
and pus. Review laboratory, x-ray, and special tests to note any abnormal results
and clarify treatments given through physician documentation.
Radiology Reports include x-ray studies, computed tomographic scans, nuclear
medicine studies, magnetic resonance imaging, arteriograms, etc. Review
radiologic reports to note any abnormal findings and clarify through additional
physician documentation within the medical record.
Special Test Reports include electrocardiograms, echocardiograms, cardiac
stress tests, etc. Review special tests to note any abnormal findings and clarify
through additional physician documentation.
o NOTE: Do not code from laboratory work, radiology, or special tests
without additional supporting documentation from the attending physician.

Step F: Review Physicians Orders

Physicians orders are written or oral orders to nursing or ancillary personnel that
direct all treatments and medications to be given to the patient. Review the
doctors orders to determine the treatments given. Diagnosis codes establish the
medical necessity for servicesan important compliance issue as it is a law that
there must be documentation to back up every code submitted on claim forms.
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o Sometimes doctors prescribe treatments without documenting the


corresponding diagnoses or conditions (as the reasons for treatment).
Therefore, you may need to query the physician to clarify a diagnosis for
coding and ask the physician to add supporting documentation to the
patients medical record.
Step G: Review Medication Administration Record

The Medication Administration Record provides documentation of the drugs


given to the patient, including the names of drugs, dosages, times given, and
routes of administration, such as by mouth, by intramuscular injection, or
intravenously. The healthcare provider administering the drug signs off on all
entries.
o If necessary for clarity, review the medical administration record to
determine medications given to help clarify or justify the diagnoses given
by the physician.

Step H: Review Discharge Summary

The discharge summary is a summary of the patients course in the hospital, the
patients condition on discharge, the discharge instructions, and the plan for
follow-up care. It includes all final diagnoses, as well as any significant principal
procedures and/or any other procedures.
o Review the DS for completeness and proper sequencing according to
UHDDS reporting rules. Physicians are often unfamiliar with coding
conventions and rules, so it is the coders responsibility to ensure that the
correct code assignment and sequencing are reported.

Step I: Query Physician

Make a list of any questions you have regarding unclear or missing information
necessary to code the encounter. Query the healthcare provider who generated
the notes. Never assume. Code only what you know from actual
documentation. If in doubt, query the physician, remembering if not documented,
not done. Without sufficient documentation, you cannot code, because
documentation is the basis of all coding.

Step J: Assign and Sequence Codes

The Coder/Abstract Summary Form on page 15 below is a form typically used by


coders to summarize their medical record review, and assign and sequence the
patients codes.

Assign inpatient codes by following UHDDS and ICD-9-CM/ICD-10-CM coding


rules and conventions.
In the outpatient setting, the term first-listed diagnosis is used in lieu of principal
diagnosis. In determining the first-listed diagnosis the coding conventions of ICD9-CM and ICD-10-CM, as well as the general and disease specific guidelines
take precedence over the outpatient guidelines
o Often, diagnoses are not established at the time of the initial encounter in
the outpatient setting and it may take two or more visits prior to a
confirmed diagnosis. The documentation to support the reason for the visit
should describe the patient's condition, using terminology that includes
either specific diagnoses and/or symptoms, problems, or reasons for the
encounter.
o In the outpatient setting, code all documented conditions that coexist at
the time of the encounter AND require or affect patient care treatment or
management. Do NOT code conditions that were previously treated and
no longer exist. However, history codes (V10-V19) may be used as
additional codes if the historical condition or family history has an impact
on current care or influences treatment. Codes for other diagnoses (e.g.,
chronic conditions the patient received treatment for, including medication
management) and care should be sequenced as additional diagnoses.
o Outpatient surgery encounter rules are to assign the diagnosis code as
first-listed for the condition that the surgery was performed. However, if
the postoperative diagnosis is known to be different from the preoperative
diagnosis at the time the diagnosis is confirmed, select the postoperative
diagnosis or condition, as this would be the most definitive diagnosis. This
is an important point: The first-listed diagnosis or condition is still governed
by circumstances of admission, which must reflect the reason the patient
is here for care. Coding a subsequent contraindication or physician/patient
determination to postpone the surgery occurs after the patient has been
admitted for the surgery, thus the reason for surgery remains as the firstlisted.
Code all diagnoses confirmed by the physician to be relevant during the
encounter. Remember that coding will report only those conditions addressed by
the provider during this encounter, not the patients entire health history. Ask
yourself WHY is the physician caring for the patient?
o When there is no confirmed diagnosis to provide medical necessity for a
procedure, service, or treatment performed, code the patients signs
and/or symptoms that led to the physicians decisions to perform that
procedure.

Connect every procedure code to at least one diagnosis code for the same
encounter for document medical necessity.
Double check your codes by back coding. This means that you look up the code
you have assigned in the tabular list, re-read the code description, and then
compare it to the original notes to make sure these match. This will help catch
typos, accidentally missing a fourth or fifth digit, numbers transposed, etc.

Additional Tips

Review records coded previously! Pay attention to what is coded and what is
not coded; and how your codes differed.
Review the CPT Evaluation/Management Coding Guidelines and Resources
in the Course Resources section when assigning E/M codes.
If you think you are on the right track with a case but you just need clarification or
reassurance, send me a message or ask a fellow student using the coding forum
in the Discussion Board link. Just do not wait until the last day that the cases
are due because you might not get a response in time!

Types of Records
Format of Records

Problem-oriented MRcontains four main parts: database, problem list, initial


plans, and progress notes. This format allows a physician to focus on the whole
patient in the context of addressing all problems. Writing progress notes in the
problem-oriented MR is referred to as SOAPing, which follows all problems
through a structured approach of Subjective Objective (data), Assessment (of
diagnoses), and Plan (for care).
Source-oriented MRforms are organized by departments or units (i.e., all
laboratory, x-ray, nurses notes, and physicians progress notes are separated),
which allows for quick comparison of data over time (e.g., results of lab work, xrays, or tests).
Integrated MRintegrates various forms and caregiver notes, arranging them in
strict chronological order to allow for a quick assessment of the patient at any
particular moment in time.

Physician Office Records

When coding these records, you are the physician office coder, which means you
are coding for the physicians office any treatment and evaluation/management
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that was done at that office during that visit and why these were done
(diagnoses) using ICD-9-CM or ICD-10-CM.
Do not code diagnoses that were not treated/addressed during the visit.
Follow ICD-9-CM and ICD-10-CM Diagnostic Coding and Reporting Guidelines
for Outpatient Services (Section IV).
Use E/M guidelines to determine appropriate E/M code.
Code procedures (services, testing, etc.) if these were done in the facility using
CPT/HCPCS codes.

Ambulatory (Outpatient) Surgery Records

When coding these records, you are the ambulatory surgery facility coder, which
means you are coding for the facility what procedure(s) were done, including
any preop testing, and why this procedure was done (diagnoses) using ICD-9CM or ICD-10-CM.
Do not code diagnoses that were not treated/addressed during the visit.
Follow ICD-9-CM and ICD-10-CM Diagnostic Coding and Reporting Guidelines
for Outpatient Services (Section IV).
Most of these cases are not going to have an E/M code unless it is a decision for
surgery case
Code procedures if these were done in the facility using CPT/HCPCS
codes. Do not forget your modifiers!

Emergency Department Records

When coding these records, you are the emergency department coder, which
means you are coding for the department what treatment and
evaluation/management was done and why these were done (diagnoses) using
ICD-9-CM or ICD-10-CM.
For accidents, do not forget your E codes.
Do not code diagnoses that were not treated/addressed during the visit.
Follow ICD-9-CM and ICD-10-CM Diagnostic Coding and Reporting Guidelines
for Outpatient Services (Section IV).
Code procedures if these were done during the visit using CPT/HCPCS
codes.
Some treatments may be done more than once during a visit, do not forget to
code multiple procedures and do not forget your modifiers!

Outpatient Services Records

When coding these records, you are the outpatient services coder, which means
you are coding for the department or the facility the procedure(s) that were done
and why these procedure(s) were done (diagnoses) using ICD-9-CM or ICD-10CM.
Procedures include anything that can be coded from CPT/HCPCS, including
supplies, radiology, laboratory work, etc.
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Do not code diagnoses that were not treated/addressed during the visit.
Follow ICD-9-CM and ICD-10-CM Diagnostic Coding and Reporting Guidelines
for Outpatient Services (Section IV).
Code procedures using CPT/HCPCS codes.
Do not forget your modifiers!

Inpatient Records

Review the tutorial posted from Michelle Green about coding inpatient records.
When coding these records, you are the inpatient coder, which means you are
coding for the hospital in order to assign the DRG.
Follow ICD-9-CM and ICD-10-CM Guidelines for Selection of Principal Diagnosis,
Reporting Additional Diagnoses, and Present on Admission Reporting Guidelines
(Section II, Section III, and Appendix I).
For ICD-9-CM Procedure codes (Volume 3) and ICD-10-PCS codes, note:
o These are only used for coding procedures performed during an inpatient
hospitalization and any procedure that affects reimbursement should be
coded and reported.
o ICD-9-CM procedure codes and ICD-10-PCS are never to be used as
diagnostic codes.
o ICD-9-CM procedure codes and ICD-10-PCS are never to be coded on
outpatient/ambulatory records.
From the Buck Step-by-Step textbook, chapter 31, Inpatient Coding:
o In the inpatient setting, ICD-9-CM procedure codes (Volume 3) or ICD-10PCS are assigned instead of CPT or HCPCS codes. Procedure codes
need to be sequenced properly with the principal procedure as the firstlisted procedure. The principal procedure is one that is performed for
definitive treatment rather than for diagnostic or exploratory purposes, or
one necessary for a complication. If two procedures appear to meet this
definition, then the one most closely related to the principal diagnosis
should be assigned as the principal procedure. A procedure is considered
to be significant if it:
Is surgical in nature
Carries a procedural risk
Carries an anesthetic risk
Requires specialized training to perform
For a procedure to be significant it does not have to be performed
in the operating room. Many procedures are performed in the
emergency department, at a patients bedside, treatment room, or
in an interventional radiology department. Any procedure that
affects reimbursement should be coded and reported.
This means you are coding diagnoses treated/addressed during the
hospitalization and major procedures (only those that are significant and impact
the DRG) using ICD-9-CM/ICD-10-CM-PCS only for diagnostic and procedural
coding.

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Inpatient coders do not assign any CPT or HCPCS codes. The physician
billing department, who is separate from your department, will assign the
physician E/M codes to bill for any physician charges that are not covered by the
DRG reimbursement. Same with radiology, laboratory, therapy, etc.; these
departments will assign CPT/HCPCS and do their own billing.

AHIMA Guidelines for Inpatient Coding


Note that inpatient coding differs from outpatient/ambulatory coding; the guidelines
below are from AHIMA for inpatient record coding for the CCS examination:

Apply UHDDS definitions, ICD-9-CM/ICD-10-CM-PCS instructional notations


and conventions, and current approved national ICD-9-CM/ICD-10-CM-PCS
coding guidelines to assign correct ICD-9-CM diagnostic and procedural codes to
hospital inpatient medical records.
Sequence the ICD-9-CM/ICD-10-CM codes, listing the principal diagnosis first.

Code

Code other diagnoses that coexist at the time of admission, that develop
subsequently, or that affect the treatment received and/or the length of stay.
These represent additional conditions that affect patient care in terms of requiring
clinical evaluation, therapeutic treatment, diagnostic procedures, extended length
of hospital stay, or increased nursing care and/or monitoring.
Code diagnoses that require active intervention during hospitalization. For
example: Admission for small-bowel ileus and subsequent aspiration pneumonia
that is treated with antibiotics and respiratory therapy. Code the ileus and
aspiration pneumonia.
Code diagnoses that require active management of chronic disease during
hospitalization, which is defined as a patient who is continued on chronic
management at time of hospitalization. For example: Admission for acute
exacerbation of COPD. The patient has depression that extends the stay and for
which psychiatric consultation is obtained. Code the COPD and depression. For
example: Admission for acute exacerbation of COPD. Physician lists "history of
depression" on face sheet, and the patient is given Desyrel. Code the COPD and
depression.
Code diagnoses of chronic systemic or generalized conditions that are not under
active management when a physician documents them in the record and that
may have a bearing on the management of the patient. For example: Admission
for breast mass; diagnosis is carcinoma. Patient is blind and requires increased
care. Code the breast carcinoma and blindness.
Code status post previous surgeries or conditions likely to recur that may have a
bearing on the management of the patient. For example: Admission for
pneumonia; status post cardiac bypass surgery. Code the pneumonia and status
post cardiac bypass surgery (V code or Z code).
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Code all procedures that fall within the code range 00.01 through 86.99, but do
not code 57.94 (Foley catheter).

Do Not Code or Assign

Do not code status post previous surgeries or histories of conditions that have
no bearing on the management of the patient. For example: Admission for
pneumonia; status post hernia repair six months prior to admission. Code only
the pneumonia. But previous surgeries involving transplants, internal devices,
and prosthetics should be coded.
Do not code localized conditions that have no bearing on the management of
the patient. For example: Admission for hernia repair; the patient has a nevus on
his leg that is not treated or evaluated. Code only the hernia and its repair.
Do not code abnormal findings (laboratory, x-ray, pathologic, and other
diagnostic results) unless there is documentary evidence from the physician of
their clinical significance. For example: Admission for elective joint replacement
for degenerative joint disease. The laboratory report shows a serum sodium of
133; no further documentation addresses this laboratory result. Code only the
degenerative joint disease and the replacement surgery. For example: Admission
for elective joint replacement for degenerative joint disease. The laboratory report
shows a low potassium level, and the physician documents hypokalemia.
Intravenous potassium was administered by the physician for hypokalemia. Code
the degenerative joint disease, the replacement surgery, and hypokalemia.
Do not code symptoms and signs that are characteristic of a diagnosis. For
example: A patient has dyspnea due to COPD. Code only the COPD.
Do not code condition(s) in the Social History section that has no bearing on the
management of the patient.
Do not assign E codes, except those that identify the causative substance for an
adverse effect of a drug that is correctly prescribed and properly administered
and/or poisoning (E850-E949).
Do not assign Morphology codes (M codes).
Do not code procedures that fall within the code range 87.01 through 99.99. But
code procedures in the following ranges:
o 87.51-87.54 Cholangiograms
o 87.74 and 87.76 Retrogrades, urinary systems
o 88.40-88.58 Arteriography and angiography
o 92.21-92.29 Radiation therapy
o 94.24-94.27 Psychiatric therapy
o 94.61-94.69 Alcohol/drug detoxification and rehabilitation.
o 96.04 Insertion of endotracheal tube
o 96.56 Other lavage of bronchus and trachea
o 96.70-96.72 Mechanical ventilation
o 98.51-98.59 ESWL
o 99.25 Chemotherapy

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Coding/Abstract Summary Form


CODER/ABSTRACT SUMMARY FORM

Medical Record #

Acct. #:

Name:

Admission Date:

Encounter Type:

Discharge Date:

Primary Payor:

Birthdate:

Sex:

Admission Type:

Length of Stay:

Discharge Disposition:
Admitting Physician:
Discharge MD:
Consultant:

CODE(S)

SHORT DESCRIPTION(S)

CODE(S)

SHORT DESCRIPTION(S)

Admit Diag
First-Listed Diag
OR
Princ Diag

Other Diag
Other Diag
Other Diag
Other Diag
Other Diag
Other Diag
Other Diag
Other Diag

Prin Proc
Other Proc
Other Proc
Other Proc
Other Proc
Other Proc

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