| Preface |
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Provider responsibility for accuracy of coding |
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Official coding guidelines for physician services |
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Coding rules for non-HCFA payers |
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Why you need written policies and procedures |
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Patient Records---The Basis of Coding |
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5 | (5) |
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Improving the documentation |
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Translating the Record into Codes---Diagnosis |
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10 | (5) |
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Translating the Record into Codes---Procedures |
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15 | (5) |
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Translating the Record into Codes---Evaluation and Management |
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20 | (10) |
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Counseling and coordination of care |
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Newborns/critical care/discharge day |
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Prolonged services/preventive medicine/care oversight |
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Decision-making documentation |
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Audit tool for E&M services |
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30 | (4) |
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Resources for You and Your Staff |
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34 | (4) |
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Payer newsletters and manuals |
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Professional organizations |
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| Appendix A. Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office) |
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38 | (3) |
| Appendix B. Data Elements for Adequate Documentation |
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41 | (7) |
| Appendix C. Bibliography |
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