ASGE Annual GI Advanced Practice Provider Course (On-Demand) - Onboarding (Day One)

Pdf Summary

This document discusses various aspects of billing and coding in healthcare. It explains the importance of coding specificity in accurately representing the clinical scenario and capturing accurate data. It highlights the different coding systems, such as AMA/CPT and HCPCS, and provides examples of specific codes for procedures and diagnoses.<br /><br />The document emphasizes the need to code to the highest specificity and to code all conditions that impact clinical decision making. It also discusses the importance of capturing social determinants of health, such as housing and economic circumstances, and provides specific ICD-10 codes for these factors.<br /><br />The document explains the components that determine the level of service, including the chief complaint, history, physical examination, and medical decision-making. It provides coding guidelines for differentiating between new and established patients and discusses the changes in coding guidelines for 2021, including the new definition for time-based coding.<br /><br />The document also covers the concept of medical necessity, the importance of documentation in supporting medical recommendations, and the role of evidence-based medicine in determining standard practices.<br /><br />Finally, the document offers some practice pearls for optimizing coding and documentation, such as developing templates, assessing workflows, and conducting coding audits. It concludes with a reminder to stay up to date with guidelines and to perform peer-to-peer clinical documentation reviews.

Asset Subtitle

Jill Olmstead, DNPc, ANP-BC, CCS-P, FAANP

Keywords

billing

coding

healthcare

coding specificity

clinical scenario

data accuracy

coding systems

procedure codes

diagnosis codes

ICD-10 codes