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
Card Set
Disposition, Billing, and Coding
course 6