Coding and Documentation CD ROM Series

Series Set (includes all 14 CDs)

Purchase the complete 14 CD set here, or purchase CDs individually below.

Volume 1: Understanding and Coding Observation Services

An overview of observation services from various perspectives: the physician provider, the hospital facility, and the insurer/payer. Physician documentation requirements, including CPT codes for the patient encounter, required orders for Medicare standards, and specific testing required for certain diagnoses, are discussed.

Volume 2: Proper Utilization of Documentation Guidelines and Chart Notes for Medical/legal Reviews and Audits

An overview of chart documentation from various perspectives: patient care, responding to audits for services rendered, and malpractice litigation. Discussion includes the duration of maintaining medical records, preserving patient confidentiality, and how to make late entries and amendments to the medical record.

Volume 3: Documenting and Coding Consultations

A review of the requirements for documenting, coding, and billing consultation services. The different levels of codes for inpatient and outpatient consultations are discussed, including a review of the guidelines for documenting evaluation and management services. The most common errors in documenting consultations are highlighted with examples of clinical notes. The discussion includes details on how to document preoperative consultations, reminders for physicians practicing with residents and fellows, and recommendations for reporting consultation services based upon time.

Volume 4: Organization and Management of a Sleep Laboratory

Review how to run a high quality, safe, and efficient sleep laboratory, and learn which type of sleep study is required for different types of patients. The discussion includes details on how to achieve sleep laboratory accreditation, the minimal requirements for properly reporting and billing an overnight polysomnogram, and how to appeal payment denials.

Volume 5: The Teaching Physician Regulations

This volume reviews the teaching physician regulations, applicable to every physician working with interns, residents, and fellows in any setting, including the outpatient office. The different supervision requirements for endoscopy, invasive procedures, and medical students are discussed in detail. Clear examples of acceptable and unacceptable linking statements to resident notes are examined.

Volume 6: Revenue Cycle Management

This volume provides a clear description of the components and processes comprising the revenue cycle, emphasizing the aspects critical-to-charge capture, claims submission, and follow-up of accounts receivables, in detail. The tools and techniques of ensuring an efficient revenue cycle are discussed, including the importance of accurate ICD-9-CM diagnosis coding, collecting all copays and coinsurances, aging of the accounts receivables, and creating different financial classes to monitor managed care contractual adjustments.

Volume 7: Nonphysician Providers (Nurse Practitioners, Physician Assistants) in Your Practice

Reveiws the options for supervising and billing clinical services offered by nonphysicinan providers in your practice, including independent billing, shared/split billing, “incident to” billing and billing under the physician’s name.

Volume 8: Documentation and Coding of Brochoscopy, Thoracentesis, Arterial and Central Venous Catheters, and Other Common Hospital Procedures

An overview of all the invasive procedure coding, emphasizing all the bronchoscopic CPT codes, but also reviewing many common hospital-based procedures, such as central line placement and thoracentesis. This CD also reviews the concept of ZZZ add-on codes, critical for accurate reporting and complete, appropriate reimbursement of bronchoscopy, and explains the differences between thoracentesis, thoracentesis with a catheter insertion, and a chest tube insertion.

Volume 9: ICD-9-CM Diagnosis Coding, Local Medical Review Policies (LMRP) and Local Coverage Determinations (LCD), Diagnosis-Procedure Edits, and Creating and Encounter Form

A detailed examination of how international Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), codes show the medical necessity for diagnostic tests and therapeutic procedures and how local coverage determinations implement payment policy for Medicare contractors by examining these ICD-9-CM codes. Also reviews how to create an appropriate encounter form for your practice, employing commonly used ICD-9-CM diagnosis and CPT codes.

Volume 10: Pulmonary Function Testing, Office Procedures, and Using Modifiers

A Comprehensive review of documentation, coding, and billing of pulmonary function testing, emphasizing spirometry, lung volumes, diffusing capacity, exercise testing, and oxygenation evaluations. The relationships between billing the professional interpretation, the technical component, and a global procedure code are explained, including the use of modifiers.

Volume 11: Critical Care

A complete examination of the regulatory requirements for providing critical care professional services, including the documentation requirements for diagnoses and time. The correct coding and report of procedures commonly performed in the ICU are reviewed, including intubations, bronchoscopy, central lines, and ventilator management, and are individually discussed. A documentation template for critical care services is provided. Also, the rules regarding critical care services in teaching hospitals and nonphysician providers are summarized.

Volume 12: Basic Documentation and Coding of Evaluation and Management Services

Every office, hospital, nursing home, and home visit with basic documentation is reported with an evaluation and management (E/M) code. This volume thoroughly reviews the basic documentation requirements for history, physical examination, and medical decision making, the three building blocks (or key components) of every E/M code. The basic types of audits currently in effect are discussed, many clinical examples are used to indicate important documentation points, and sample documentation templates are provided.

Volume 13: Overview of Reimbursement

Discussions of physician reimbursement mechanisms can appear as alphabet soup in a foreign language. This volume provides historical perspective and clear definitions of CPT codes, the resource-based relative value system, and relative value units and describes how the American Medical Association (AMA) creates new CPT codes and the AMA Relative Value Update Committee values the physician work and practice expenses for each CPT code. Also included is a description of how the Centers for Medicare and Medicaid Services (CMS) creates the Medicare Physician Fee Schedule and a summary of how managed care organizations utilize portions of CPT coding and the Medicare Fee Schedule in creating their own proprietary physician payment mechanisms.

Volume 14: Vaccines and Infusion Codes

Learn the entire new series of codes created for vaccinations, IV hydration, and drug administration (including infusion) in 2005. Identify the appropriate coding of outpatient parenteral medication administration, including antibiotics, monoclonal antibodies, biologic response modifiers, and chemotherapy.