Disposition, Billing, and Coding

  1. What are the 4 types of dispositions?
    • Discharge
    • Admitted
    • Transferred
    • Against Medical Advice (AMA)
  2. 4 things to document for a Discharge
    • time of disposition
    • suggested follow up + time period
    • specific conditions for return to ED
    • “stable for discharge”
  3. 4 things to document for an Admit
    • admission location and time
    • who the admitting physician is
    • time of consult with admitting physician
    • condition of pt (good, fair, serious, critical)
  4. 4 things to document for a Transfer
    • time of consult w/accepting facility + name of physician
    • “pt stable for transfer”
    • “ED records accompanying pt”
    • “appropriate mode of transfer arranged”
  5. 8 things to document for AMA
    • date + time of AMA discussion
    • AMA form
    • specific risks and benefits of proposed treatment
    • pt’s reason for refusal
    • consequences of leaving AMA
    • self-care instructions
    • any outside arrangements (police, social services, relatives)
    • pt’s mental capacity
  6. What is needed for a level 5 chart?
    • 4 HPI elements
    • 10 organ systems for ROS
    • 2 PHx elements
    • 8 PE organ systems
  7. What to document for EKG findings?
    • rate
    • rhythm
    • 2 additional findings
  8. What to document for X-Ray interpretations?
    • at least 3 findings
    • “interpreted by EP”
  9. What is the main goal of ICD-10 documentation?
    to be as accurate and specific as possible
  10. The 4 common oxygen routes
    • room air (RA)
    • nasal cannula (NC)
    • face mask (FM)
    • non-rebreather mask (NRB)
  11. Normal vital signs for Heart Rate?
    60-100 bpm
  12. Normal vital signs for blood pressure?
    90/60 - 140/90
  13. Normal vital signs for oxygen saturation?
    96% or above on room air
  14. Normal vital signs for temperature?
    97 - 99 degrees F
  15. 4 Critical care oxygen routes + when they are used
    • continuous positive airway pressure (CPAP): delivers cont. air pressure, sleep apnea pt
    • biphasic positive airway pressure (BiPAP): machine alternates pushing air in and out
    • bag valve mask (BVM): used pre-procedures, manually inflates lungs
    • endotracheal tube (ETT): used during respiratory failure
  16. What is the purpose of MACRA?
    • an initiative to cut down healthcare costs
    • to switch from volume focus to quality
  17. Disposition
    The patient’s destination after they leave the Emergency Department
  18. Diagnosis
    The process of determining which disease or condition explains a person's symptoms and signs
  19. Hospitalist
    Physician who cares for a hospitalized patient
  20. E&M Levels
    Set of criteria that determine how a physician can be paid for their services
  21. Level 5
    The highest level of billing
  22. Down-coded
    When a physician can only be reimbursed for a lower level of care due to inadequate documentation
  23. Caveat
    A disclaimer
  24. Quality Measure
    A national standard among Emergency Physicians that dictates the care and documentation required for each diagnosis or complaint
  25. Protected Health Information
    Any information that can be tied to a particular patient
  26. HIPAA
    A body of laws designed to protect private health information of patients
  27. HITECH
    Privacy laws related to electronic transmission of health information
Author
st2478
ID
343285
Card Set
Disposition, Billing, and Coding
Description
course 6
Updated