Medical Coding Basics — Cardiology (Part 1) [ Ссылка ]

Alicia: Q: [Medical Coding Basics - Cardiology] I am having trouble putting it all together! Reading a question and figuring out what to do in cardio issues. Can you go over cardio?

A: What I decided to do was take a couple cases and these are real cases redacted with people that have cardio issues. Just show you how to abstract, what to look for when you’re going to be coding a case with somebody in cardiology. These may not be just cardiology, they could be a practice, but they actually are cardiology cases.

The very first one is she’s coming in for her yearly checkup. And as I peruse this encounter, I tend to always go to the bottom and go up from the bottom because when you’re doing risk adjustment stuff, part of that is an auditing aspect, you have to make sure the signatures are all valid, and so on and so forth.

What I’ll do is I’ll come down here and I want to know what the assessment is, the assessment is the diagnosis. Sometimes they’ll say diagnosis, sometimes it will say assessment. I know this, he is assessing that this patient has right renal artery hyperplasia, hypertension and palpitations. Then, I can look here real quick and say, “Yeah, sure enough, there’s a plan of care that addresses all of that,” so those are three codes that I know I’m going to be looking at.

I go back up and let’s see what’s going on with the patient, see if there’s anything else that we can capture. Right here on the first one I see left ventricular diastolic dysfunction secondary to hypertension. OK. Then, we have fibromuscular hyperplasia of the right renal artery per arteriogram – we knew we were going to code that – hypertension and mild hypercholesterolemia.

Then I look at the medications. When you’re doing risk adjustment and HCC coding, you have to draw a line; so I see something that’s going to be a diagnosis, I want to see if there’s a medication, that’s the easiest way to draw a line. But on top of that, you’re going to go down here and say, “OK, this is the history that they’re taking, blood pressure is mentioned. The patient has palpitations; that’s mentioned.” These are words that leap off the page at me. Also, we see that they took the vital signs, which is probably always going to happen. Again, that tells you that the person has hypertension, or you have a backup that this is being addressed.

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