Highest Level of Specificity Essential Processes in Healthcare Analysis
To ensure accuracy in documentation and receive fair compensation, health care providers should code to the highest level of specificity.
Create a training document illustrating examples of how to code to the highest level of specificity.
Your role: Practice administrator
Audience: Physicians and Coders in your practice
Objective: Training/reference guide for assigning codes
One paragraph explaining why coding should be to the highest level of specificity.
Bullet point format: Six (6) examples of appropriate codes that align with specificity best practices. Format should include the code itself, followed by the code’s description. Examples:
* E10.65 Type 1 diabetes with hyperglycemia
* S06.0x1A Concussion with loss of consciousness of 30 minutes or less, initial encounter
One paragraph explaining the process for correcting codes internally if they are not coded to the highest level of specificity – before they are sent to the payer. This will be specific to your practice’s workflow and staffing (fictional information, you create based on your research and knowledge).
Headache Process and Diagnostics Discussion
Process and Diagnostics
Your objective is to determine diagnostic workup based on the differential diagnosis for clients presenting with an episodic illness in the care setting.
Headache is an exceedingly common symptom in primary care and other practice settings, ranking among the top 10 most frequent symptoms that prompt an office visit. Diagnosis and management are based on a careful clinical approach augmented by an understanding of the anatomy, physiology, and pharmacology of the nervous system pathways that mediate the various headache syndromes.
A 35-year-old woman comes to your office to discuss her “bad headaches,” which started after having her first child 2 years ago. The headaches sometimes awaken her from sleep and at times can be disabling and occasionally require her to take Tylenol and rest in a dark room. Sometimes she vomits during an attack. Over the past 6 months, her headaches have become more severe and frequent, prompting her visit today.
What additional questions would you ask to learn more about her headaches?
How do you classify headaches?
How can you determine if this is an old headache or a new headache/s? Is this a chronic or episodic condition?
Can you make a definite diagnosis through an open-ended history followed by focused questions?
How can you use the patient history to distinguish between benign headaches and serious ones that require urgent attention?
What diagnostic tests do you want to include to help you with your diagnosis? Who might you refer this patient to see and why?
Create a differential diagnosis flow sheet for this patient and include the diagnostics related to the differentials.