Em-Coding Essay Sample
One must determine the category and subcategory of service in order to know the type of patient one is dealing with. Location of the service and patient’s health are essential when determining the category which a patient belongs.
Documented history must be reviewed for it to be related with present coding, it includes: Chief Complaint (CC), History of Present Illness (HPI), Review of Systems (ROS), Past Medical, Family and Social History (PFSH) Jbeerwei (2003).
The extent of the documented examination taken has to be checked since is crucial since it forms basis of the examinations to be carried out or to be prescribed to a patient. This will entail checking the problem focused, expanded problem focused, detailed and or, comprehensive problem focused.
Complexity of the medical decision making what is documented must be determined. It is in four levels: straightforward, low complexity, moderate complexity, and high complexity. Assessments, clinical impressions, diagnosis and level of risk should be checked.
All requirements to present the service level should be analyzed. This involves pooling the aspects of one level and comparing to the patient in question. Verification of the surface level should be done basing on the nature of the problem, time, counseling and care coordination. Documentation should be verified if it is complete by checking all the above six steps and once this is complete the code which may be preventive medicine code , consultation code, and immunization code.