Chapter 1: The Medical Record Practice Flashcards

The Medical Record and the Role of the Coder

  • The Medical Record Defined: Documentation of any encounter between a patient and a medical provider. This includes primary care visits, specialist consultations, emergency room visits, urgent care episodes, and diagnostic services such as X-rays.

  • Primary Responsibility of a Medical Coder: To interpret medical record documentation and translate it into alpha-numeric codes. This requires a comprehensive understanding of the information contained within the medical record.

  • Common Types of Medical Record Entries:

    • Evaluation and Management (E/M) Documentation: Created when a provider evaluates and manages a patient's condition. These services occur in various locations, including office settings, hospitals, or nursing homes.

    • Operative Reports: Documentation generated when a provider performs a surgery, ranging from minor procedures (e.g., excision of a skin lesion) to major surgeries (e.g., hip replacement).

    • Radiology Reports: Created when a provider interprets a radiology image. The report constitutes the interpretation of conditions visualized on the image.

    • Laboratory Reports: Generated when specimens (blood, skin, fluids, etc.) are analyzed by lab equipment. Providers commonly add notes to these results.

    • Surgical Pathology Reports: Specific lab reports documented by a surgical pathologist after reviewing a specimen.

Evaluation and Management (E/M) Documentation

  • Overview of E/M Visits: These encounters involve a provider visit for evaluation, such as annual wellness checks or assessments of specific symptoms, diseases, or ailments. They are not limited to a single medical specialty or body system.

  • Evaluation Methods:

    • Observation/Inspection: The physician observes mannerisms, behavior, skin, and body symmetry for abnormalities.

    • Palpation: Examination of the body by touch to evaluate organ size, condition (e.g., abdominal masses), or tenderness.

    • Auscultation: Listening to body sounds, typically using a stethoscope to assess the heart and lungs.

    • Percussion: Tapping on body areas to create sounds that help examine internal organs and cavities. For example, lungs should sound hollow when percussed.

  • Common E/M Abbreviations:

    • BP: Blood pressure

    • CC: Chief complaint

    • HEENT: Head, eyes, ears, nose, throat

    • h/o: History of

    • HPI: History of present illness

    • Hx: History

    • NAD: No apparent distress

    • NKDA: No known drug allergies

    • PE: Physical examination

    • PERRLA: Pupils equal, round, and reactive to light and accommodation

    • PMH: Past medical history

    • pt: Patient

    • R/O: Rule out

    • ROS: Review of systems

    • WNL: Within normal limits

  • Standard Encounter Components:

    • Chief Complaint: The reason the patient is presenting for services.

    • History: The patient's description of symptoms prompting the visit.

    • Physical Examination: Assessments and observations focused on the patient's symptoms.

    • Assessment and Plan: The determination of a diagnosis (assessment) and the subsequent strategy (plan) to resolve or relieve symptoms.

The SOAP Format

  • S - Subjective: Information provided by the patient regarding symptoms and any self-treatment efforts.

  • O - Objective: The provider's physical exam findings and vital signs.

  • A - Assessment: The provider's determination of the condition, indicating a definitive or working diagnosis. In the absence of a diagnosis, signs and symptoms are documented.

  • P - Plan: The documented strategy related to the assessment, including ordered tests and the provider's thought process when a diagnosis is pending.

Detailed Example: Orthopedic Office Visit

  • Chief Complaint (CC): Shoulder injury.

  • Patient Presentation: Referred by primary care for a shoulder injury sustained during football practice.

  • Subjective Dialogue:

    • Question: What brings you here?

    • Response: I was tackled in football practice and landed on my shoulder. I went to see my primary care provider and he referred me here.

    • Question: Where does it hurt?

    • Response: In the right shoulder.

    • Question: How long has it been hurting?

    • Response: Since I was tackled.

    • Question: Is there anything that you have taken or done that make the pain better or worse?

    • Response: No, my parents thought it would get better with time, but it continues to get worse.

    • Question: Is your shoulder stiff?

    • Response: No, just hurts.

    • Question: Do you have pain in other joints, or just the shoulder?

    • Response: No, just the shoulder.

    • Question: Do you have any numbness or tingling?

    • Response: No.

    • Question: Do you take any medications regularly?

    • Response: No.

    • Question: Are you allergic to any medications?

    • Response: No.

  • History of Present Illness (HPI): Patient referred for consultation following a football injury where he was tackled and landed on his right shoulder. Pain has persisted and worsened since the incident.

  • Review of Systems (ROS):

    • Const: Denies chills, fatigue, fever, weight change. Health is good.

    • Eyes: Denies visual disturbance.

    • CV: Denies chest pain, palpitations.

    • Resp: Denies cough, dyspnea, wheezing.

    • GI: Denies constipation, diarrhea, dyspepsia, dysphagia, hematochezia, melena, nausea, vomiting.

    • GU: Denies dysuria, frequency, hematuria, incontinence.

    • Musculo: Denies arthralgias, myalgia.

    • Skin: Denies rashes.

    • Neuro: Denies neurologic symptoms.

  • Objective Vitals:

    • BP: $118/78$

    • Pulse: $76$

    • T: $98.0$

  • Physical Exam (Exam):

    • Const: Appears obese; NAD.

    • ENMT: Normal auditory canals and tympanic membranes; pink/moist nasal mucosa; dentition in good repair; posterior pharynx clear of exudate/redness.

    • Neck: No lymphadenopathy or masses; thyroid is normal (no thyromegaly); no JVD.

    • Resp: Normal respiration rate; clear lungs bilaterally; no wheezing.

    • CV: Regular rate and rhythm; no murmurs.

    • Extremities: No clubbing, cyanosis, or edema. Right shoulder is tender with no deformation but decreased ROM in abduction and extension.

    • Abdomen: Normoactive bowel sounds; no tenderness, guarding, or rebound; no palpable hepatosplenomegaly.

    • Musculo: Normal gait.

    • Skin: Warm and dry.

  • Assessment and Plan:

    • Assessment: Joint pain in shoulder region ($R/O$ clavicle fracture or rotator cuff injury).

    • Plan: Shoulder X-ray (minimum two views); report to primary care.

The Operative Report

  • Definition: A note produced immediately after a surgical procedure summarizing findings, procedures performed, specimens removed, diagnoses, and participating staff.

  • Structure of the Operative Report:

    • Header: Patient name, date, pre-/postoperative diagnoses, procedure name, surgeon, assistants, anesthesia, and anesthesiologist.

    • Indications: Brief history outlining the medical necessity for the procedure.

    • Detail/Body: Step-by-step description of the surgery, beginning with the "time out" verification, prepping/draping, approach, intra-operative findings, and any complications.

    • Findings/Conclusion: Includes estimated blood loss (EBL) and patient status at completion.

  • Example 1: Skin Lesion Excision:

    • Pre-/Postoperative Diagnosis: Large dysplastic nevus, right chest.

    • Procedure: Excision of $1.2\,cm$ diameter nevus with $0.5\,cm$ margins; complex repair of $4.0\,cm$ wound.

    • Anesthesia: Local ($20\,cc$ of $1\%$ lidocaine with epinephrine).

    • Technique: Supine position; sterile prep; excision into subcutaneous fat; hemostasis via Bovie cautery; extensive undermining and retention sutures used due to skin tension; layered closure with 4-0 Monocryl and 5-0 Prolene.

  • Operative Report Coding Tips:

    1. Highlight and research unfamiliar terms.

    2. Use the post-operative diagnosis for coding (unless pathology results provide more detail).

    3. Verify all procedures listed in the header by reading the body of the note.

    4. Identify keywords: anatomical location, approach (laparoscopic vs. open), method (debridement, repair), and instruments used.

Detailed Case Study: Hand Surgery

  • Patient: Jane Smith

  • Preoperative Diagnosis: Left long finger distal phalanx transphyseal fracture with displacement of the epiphysis.

  • Postoperative Diagnoses: 1. Left long finger distal phalanx transphyseal fracture with displacement of the epiphysis. 2. FDP disruption at its insertion.

  • Specific Terminology:

    • FDP: Flexor Digitorum Profundus (forearm muscle).

    • DIP Joint: Distal interphalangeal joint (joint nearest the fingernail).

    • Esmarch: Soft rubber bandage used to expel blood from a limb prior to surgery.

    • Takedown: The undoing or reversal of a previous surgical state or procedure (e.g., malunion takedown).

    • C-Arm: A portable fluoroscopy (X-ray) machine shaped like a "C".

  • Procedure Details:

    • Approach: Y-shaped volar incision using a 15-blade; dissection around neurovascular tissues.

    • Findings: Complete physis displacement and FDP disruption; malunion present.

    • Fixation: Fragment reduced and held with $3.5$ K-wire; DIP held in hyperextension; alignment verified via C-arm.

    • Tendon Repair: Bunnell technique using 3-0 Prolene suture; brought out through the nail via two Keith needles and tied over a button.

    • Closing: $5-0$ chromic suture; dorsal blocking splint applied.

Radiology Reports

  • Requirements: Must include the image (retained by facility), the written report, the indication/reason for the study, and the summarized findings.

  • Mandatory Report Elements: Patient/Physician info, study date/time, extent of exam (limited vs. complete), number/type of views, contrast details (type, amount, route), and radiologist signature.

  • Common Radiological Views and Terms:

    • Anteroposterior (AP): Front to back.

    • Posteroanterior (PA): Back to front.

    • Decubitus (DEC): Patient on their side.

    • Oblique (OBL): Angled view (e.g., RAO, RPO, LAO, LPO).

    • Odontoid: Open mouth view for C1 joint space.

    • Swimmers: Thoracic X-ray with arms overhead.

    • Stereo: Two views at different angles.

    • Apical lordotic: Chest view focusing on the lung apex.

    • Body Planes: Coronal (front/back), Sagittal (left/right), Transverse (top/bottom).

  • Example: CT Report:

    • Technique: Axial images of chest, abdomen, and pelvis using oral and $125\,cc$ Omnipaque-300 IV contrast.

    • Chest Findings: Left upper lobe mass ($83 \times 64\,mm$, previously $76 \times 56\,mm$); centrally necrotic; coronary arteriosclerotic calcification.

    • Abdomen/Pelvis Findings: Normal organs (liver, pancreas, spleen, etc.); degenerative changes in lumbar spine; left-sided muscle atrophy.

Pathology and Laboratory Reports

  • Documentation Standards: Physicians must note the test type, methodology, and normal range. They must comment on whether a finding is normal or abnormal. Results should be signed and addressed in the treatment plan.

  • Variability: Normal ranges differ between laboratories; physicians must interpret results based on the specific lab's standards.

  • Billing: Typically billed by the lab performing the service. Medicare reimburses outpatient lab services via a fee schedule.

  • Case Study: Surgical Pathology:

    • Specimen: Right mid-transmetatarsal amputation (distal right foot including 2nd, 4th, and 5th toes, measuring $9.0 \times 9.0 \times 4.0\,cm$).

    • Clinical Data: Chronic infected skin ulcer status post amputation of 1st and 3rd toes.

    • Gross Description: Ulcer at the bottom of the foot near the 2nd toe ($1.5 \times 1.5 \times 0.7\,cm$); bone piece ($2.4 \times 1.3 \times 1.3\,cm$) submitted for decalcification.

    • Final Diagnosis: Right foot with ulceration; histologically viable margins; no evidence of active osteomyelitis in decalcified bone specimen.

    • Additional Finding: Geographic fibrinoid necrosis, suggesting potential rheumatoid nodule.