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Guidelines to follow in Coding forPostoperative Pain in ICD-10-CM

7 Jan

Normally Postoperative pain is considered as a normal phase of healingmethod following many types of surgery. Such pain is frequently kept undercontrol using typical measures like pre-operative, non-steroidal, provocativemedications; local anesthetics that is injected into the operative wound beforesuturing; postoperative analgesics; and even intra-operative or post-operativeinjection of epidural analgesics, that form many kinds of surgeries.

When post operative pain is documented to the current, which is far awayfrom the routine and expected for the appropriate surgical method surgical, doyou think it is a reportable diagnosis. Also note that coding for Postoperative pain in ICD-10-CM, which is not considered on daily basis or expected further in future, iscategorized by whether the pain is pertaining with a definite, documentedpostoperative complication.

Extreme coding forPostoperative Pain in ICD-10-CM not reported due to a Specific PostoperativeComplication

Remember that Postoperative pain not related with a precisepostoperative complication is conveyed with a code from Category G89, This Painnot shown or classified anywhere else.

Postoperative pain in ICD-10-CM mainly has four codes as given below.

G89.12 Acute post-thoracotomy pain;

G89.18 Other acute post-procedural pain;

G89.22 Chronic post-thoracotomy pain; and

G89.28 Other post-procedural pain that is chronic

In any case, if the documents fail to mention whether the post-thoracotomyor post-procedural pain is acute or chronic, consider the default is acute.

Extreme level of PostoperativePain reported Due to a Specific Postoperative Complication

Any coding for Postoperative pain reported that is taking place due to a specific postoperative complication isalways documented with its specified code for that particular complication thatalso includes Injury, poisoning and many other consequences of external causes.There is an extra additional code from category G89 that may be documented todefine the pain more appropriately whether it is post-thoracotomy or otherpostoperative pain, which is acute or chronic in nature.

Before we get into any discussion of postoperative pain generating dueto a definite postoperative difficulty, it is very crucial to fully apprehendthe general guidelines pertaining to coding of complications of care, which aredescribed in Section I.B.16 of the draft version in year 2013 of the ICD-10-CMOfficial Guidelines and Reporting. All these guidelines are very much alike tothose that are present in ICD-9-CM. The main factors to bear in mind whencoding complications of care are given below:

  • Allotment of code depends on theprovider’s reporting of the relationship between the situation and the medicalcare or method used.
  • Remember, not all conditions occurringduring the course of medical care or carrying out procedures are considered ascomplications.
  • In any case, if you find the reportingdone is not clear, you reserve the right to question the person concerned whowrote it.

AboutMediscribes

Mediscribes, Inc. is one of the fastest growing Medical Transcription & document management systems providers in United States,based in Metro Louisville. Mediscribes is an ISO 9000-2001 certified company,rendering cost-effective consolidated transcription solutions to majorhospitals, clinics, and other healthcare facilities in United States.Mediscribes is the most value-providing organization in the market today with astrong presence in America and offshore locations. The firm specializes inproviding highly accurate transcription adhering to ADHI guidelines inunbeatable turnaround time with robust & proven document management systemas its vantage point to its esteemed clientele.

Mediscribes provides end-to-end transcription solutions as itsprimary offering. For our customers, we focus on dictation systems, both ASP aswell as enterprise level solutions, with the help of our most valued asset   ezVoiceIntelligence (ezVI), providingspecialty-specific qualitative transcription along with a “whole nine yards”document management system. Mediscribes specializes in EMR data integration aswell. Our data dispatch department is highly proficient in integrating transcribedreports into any type of EMR. Healthcare facilities that do not have EMR getthe option to use our web-based file monitoring interface called eTranscribefor global access to their data. eTranscribe has special features of E-signing,E-faxing, auto-printing, and user-friendly document search criteria.

For additional information, please visit http://www.mediscribes.com

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ICD-10-CM Official Guidelines for Coding andReporting in 2013

26 Dec

Confront the latest medical coding challenge ICD-10-CM coming onOctober 1, 2014.

What is ICD-10-CM?

ICD-10-CM also known as “InternationalClassification of Diseases” is generally a set of codes largely utilized mainlyby the physicians, hospitals, Medical Transcription Companies andhealth care expertise or specialists in order to perform an analysis onpatients every visit. The ICD-10-CM system of coding contains approximately68,000 codes and these codes become essential when claiming for any type ofhealth insurance in the U.S.

If we compare ICD-9-CM, we find veryfew alterations are done with ICD-10-CMDraft code set for 2013 which will beeffect from 1st October, 2014. It was decided to make a few changesin the 2013 ICD-10-CM Draft code, by accumulating a couple of terms andrectifying typos in the Alphabetic directory.

Let’s check out the probableadvantages of implementing the latest ICD-10 medical coding system:

  • Applicationof this code gives expansion of injury
  • Datais collected based on site rather than type of injury
  • Mixtureof diagnosis codes
  • Calculationof sixth character using some codes extended out o the seventh character
  • AddingV and E codes into the main classification

The alterations done by medicaltranscription companies signify huge development over ICD-9-CM and ICD-10.

Some specific improvements done aregiven below:

  • Prolongedinjury codes due to adding up of data pertinent to ambulatory and managed careencounters
  • Byimplementing a new concept of combination diagnosis/symptom codes, the numberof codes actually needed to explain a condition lessens.
  • Accordingto the news, HHS on January 16, 2009, issued a final rule wherein it hasaccepted ICD-10-CM (and ICD-10-PCS) to replace ICD-9-CM in HIPAA transactions.

Impact On Your Medical Coding Employees

This latest system of ICD-10-CM medical coding will bringtremendous level of progress for all the medical transcription companies andU.S. health care system.  The presentsystem of ICD-9-CM is outdated for new codes and limits the coding process. Asmedical transcription person, you require, to familiarize yourself with thelatest system and get the significant training for the same to ensure a smoothtransition.

Ifyou are a medical coder or any professional pertaining to medical servicescompany then it is mandatory for you to get a comprehensive synopsis about theessential changes in store for both diagnostic and procedural coding.

  • Apartfrom this, you will be required to get information at length on the impacts ofthe coding changes. The reason behind following this procedure is becauseOctober 1st, 2013 is the last date for compliance. All medical serviceproviders such as Medical Transcription ServiceProviders be it doctors or any other personal offering his medicaltranscription services, it will become necessary for them to get acquaintedwith the new system.
  • Youwill need to register yourself in an ICD-10-CM medical coding course in orderto study the new medical coding system, containing approximately 55,000 morecodes. This is not it, a lot more is yet to follow thus, please keep updatedwith the latest and upcoming modifications.

Even supposingchanges done may be little to ICD-10-CM Draft system of coding for the nextcouple of years, we suggest you as a medical coder to study the guidelinescarefully and yearly. Aside from this, you can expect supplementary guidelinesand reporting coming up as we have additional coders training under ICD-10-CM.

About Mediscribes

Mediscribes, Inc. is one of thefastest growing Medical Transcription & document management systemsproviders in United States, based in Metro Louisville. Mediscribes is an ISO9000-2001 certified company, rendering cost-effective consolidatedtranscription solutions to major hospitals, clinics, and other healthcarefacilities in United States. Mediscribes is the most value-providingorganization in the market today with a strong presence in America and offshorelocations. The firm specializes in providing highly accurate transcriptionadhering to ADHI guidelines in unbeatable turnaround time with robust &proven document management system as its vantage point to its esteemedclientele.

Mediscribes provides end-to-endtranscription solutions as its primary offering. For our customers, we focus ondictation systems, both ASP as well as enterprise level solutions, with thehelp of our most valued asset  ezVoiceIntelligence (ezVI), providing specialty-specific qualitativetranscription along with a “whole nine yards” document management system.Mediscribes specializes in EMR data integration as well. Our data dispatchdepartment is highly proficient in integrating transcribed reports into anytype of EMR. Healthcare facilities that do not have EMR get the option to useour web-based file monitoring interface called eTranscribe for global access totheir data. eTranscribe has special features of E-signing, E-faxing,auto-printing, and user-friendly document search criteria.

For additional information,please visit http://www.mediscribes.com

Mediscribes is distributor of Provox products for speech-driven workflow

28 Nov

Mediscribes, Inc., a fast growing Medical Transcription provider, is a distributor for the Provox products for speech-driven workflow reporting.

Provox VoxReports is a front-end speech recognition system for radiology reporting and workflow management. VoxReports supplements radiologist dictation with front-end speech recognition and macros, automating the workflow between radiologists and transcriptionists. Provox VoxNotes, a front-end speech recognition system for clinical reporting, automates the workflow between clinicians and transcriptionists and includes capabilities for charting.

Based in Louisville, KY, Mediscribes is one of the fastest growing transcription and document management solution providers in United States. “The Provox products are a good fit for our provider clientele seeking a cost-effective dictation and workflow solution,” said Vatsal Ghiya, President and CEO of Mediscribes. “We will be offering a very competitive per-report pricing model that should be appealing to imaging centers looking to gain the advantages of turn-around time improvements at a very reasonable cost.”

“We’re excited that Mediscribes will be distributing the Provox products,” said Steve Backes, President and CEO of Atirix.

“Mediscribes specializes in small to medium sized hospitals and clinics, where Provox products have proven to be a good value. Compared to template driven documentation and EMRs, transcription combined with speech recognition captures the patient story in a more meaningful and comprehensive way and also significantly improves the productivity of the clinician. The Provox products will be a good strategic fit for Mediscribes and their clients.”

Mediscribes is an ISO 9000-2001 certified company, rendering cost-effective consolidated transcription solutions to major hospitals, clinics, and other healthcare facilities. The firm specializes in providing highly accurate Transcription Services, while adhering to the Association for Healthcare Document Integrity (AHDI) guidelines. Mediscribes has a wide network of highly-skilled transcriptionists, editors and quality assurance professionals servicing more than 2,000 providers and producing over 40 million lines of transcribed dictation.

Atirix Medical Systems, of Minneapolis, MN, develops quality assurance and workflow products for diagnostic imaging centers. The patented Provox software system features SmartMacros for dynamic report formatting and includes system management tools for workflow customization, administrative controls, and performance reporting.

For more information please contact Mediscribes at 866-473-5655 or http://www.mediscribes.com. Mediscribes and Atirix will be together at RSNA in the Atirix booth, South Hall, #4703.

About Mediscribes

Mediscribes, Inc. is one of the fastest growing Medical Transcription & document management systems providers in United States, based in Metro Louisville. Mediscribes is an ISO 9000-2001 certified company, rendering cost-effective consolidated transcription solutions to major hospitals, clinics, and other healthcare facilities in United States. Mediscribes is the most value-providing organization in the market today with a strong presence in America and offshore locations. The firm specializes in providing highly accurate transcription adhering to ADHI guidelines in unbeatable turnaround time with robust & proven document management system as its vantage point to its esteemed clientele.

Mediscribes provides end-to-end transcription solutions as its primary offering. For our customers, we focus on dictation systems, both ASP as well as enterprise level solutions, with the help of our most valued asset   ezVoiceIntelligence (ezVI), providing specialty-specific qualitative transcription along with a “whole nine yards” document management system. Mediscribes specializes in EMR data integration as well. Our data dispatch department is highly proficient in integrating transcribed reports into any type of EMR. Healthcare facilities that do not have EMR get the option to use our web-based file monitoring interface called eTranscribe for global access to their data. eTranscribe has special features of E-signing, E-faxing, auto-printing, and user-friendly document search criteria.

For additional information, please visit http://www.mediscribes.com

5 Definite Reasons To Integrate Transcription With EMR System

5 Nov

Medical transcription business has reached a new milestone with the integration of eMR. In this article; we look at different reasons to integrate transcription services with eMR system.

With the emergence of Electronic Medical Record (EMR) system; there was a big question mark over the medical transcription industry. But with the synchronization of both these processes medical practitioners have been able to save lot of time, increase productivity and get accurate documentation in a timely manner. Let us now look at some of the reasons to integrate transcription with eMR system:

  • Quick and efficient output: Medical practitioners are usually busy in their clinics/practices so they do not have time to type patient’s notes into eMR system. Hence; dictation systems helps medical practitioners in saving time and directly integrates the transcribed document in eMR system. This enables the doctors to keep up the pace with their productivity rate.
  • Synchronization with eMRs: eMRs have significantly reduced the workload of medical transcriptionists. With the help of the software the transcribed documents can be directly inserted in the eMR of the respective medical practitioner by using Discrete Reportable Transcription (DRT). eMRs are meeting the “meaningful use” requirements, and a complete and accurate patient visit record is being recorded.
  • Generates profit: It becomes quite cumbersome for the medical practitioners to stop typing into eMR during each patient visit. This results in reduced patients which ultimately reduces the profit. Using a lucrative dictation system, medical practitioners can continue to see more patients thereby increasing the profits.
  • Decreases data-entry costs: Medical practitioners cannot be used for data-entry tasks. They are too good of a resource to be wasted on data-entry tasks. If you hire an in-house medical transcriptionist you need to pay salary and benefits. Voice recognition systems are too costly and show a higher error rate than a human transcriptionist.
  • Accuracy of information: If the medical practitioners type their own notes it can lead to higher error rate. Usually they have to shift from one appointment to another which can affect the accuracy of the notes. Also there are times when medical practitioners use copy-paste or copy-forward function on eMR which results in inaccurate information being stored on patient’s record.

With the amalgamation of eMR with Medical Transcription business it becomes very easy for Medical Practitioners to conduct their day-to-day activities. A global medical transcription company exploits the services of eMR in an expertise manner; and gets the transcribed documents done in a quick time.

About Mediscribes

Mediscribes, Inc. is one of the fastest growing Medical Transcription & document management systems providers in United States, based in Metro Louisville. Mediscribes is an ISO 9000-2001 certified company, rendering cost-effective consolidated transcription solutions to major hospitals, clinics, and other healthcare facilities in United States. Mediscribes is the most value-providing organization in the market today with a strong presence in America and offshore locations. The firm specializes in providing highly accurate transcription adhering to ADHI guidelines in unbeatable turnaround time with robust & proven document management system as its vantage point to its esteemed clientele.

Mediscribes provides end-to-end transcription solutions as its primary offering. For our customers, we focus on dictation systems, both ASP as well as enterprise level solutions, with the help of our most valued asset   ezVoiceIntelligence (ezVI), providing specialty-specific qualitative transcription along with a “whole nine yards” document management system. Mediscribes specializes in EMR data integration as well. Our data dispatch department is highly proficient in integrating transcribed reports into any type of EMR. Healthcare facilities that do not have EMR get the option to use our web-based file monitoring interface called eTranscribe for global access to their data. eTranscribe has special features of E-signing, E-faxing, auto-printing, and user-friendly document search criteria.

For additional information, please visit http://www.mediscribes.com

Media Contact (Mediscribes)

Mike Perry

marketing@mediscribes.com

Mediscribes

12806 Townepark Way

Louisville, KY 40243-2311

Ph: 502-400-9374

http://www.mediscribes.com

http://www.bizscribes.com

8 Definitive Skills Required in Medical Transcriptionists

29 Oct

Medical transcriptionists need to have certain key skill-sets to be successful in medical transcription domain. In this article; we look at distinct skill-sets required by medical transcriptionists in medical transcription business.

Medical transcription business is expanding on a daily basis. We are already seeing a lot of demand for specialized services of medical transcriptionists in the market. There are several skill sets required for a medical transcriptionist to be successful in their profession. Let us look at these skills individually:

  • Exceptional control over grammar, spelling and punctuation:  Medical transcriptionist should have exceptional spelling skills. It is always recommended for the medical transcriptionist to have a dictionary with them but do not ponder over the words excessively; because most probably they are paid for the amount they type. Good grammar skills and punctuation marks will give them an edge over their competitors.
  •  Concentration for longer period of time: A medical transcriptionist needs to sit in front of computers for longer period of time. Good focus on the transcribed document can reduce the number of mistakes in the patient’s medical report. Mistakes can endanger the lives of patients hence; proper care needs to be taken while transcribing the document.
  • Work without supervision and stay motivated: Sometimes medical transcriptionists need to work from home. At that point, it becomes very important for them to stay motivated so that they can work without any supervision. Turnaround time for the reports need to be met; as a report is due in only one or two hours after it is dictated.
  • Exceptional research skills:  A medical transcriptionist must have excellent research skills. They should not only have the right reference books, but they should also be able to pick the right book quickly. The medical transcriptionist should be able to find hospitals and physicians; in case if there is any spelling mistake or abbreviations.
  • Above average typing skills: Good typing skills are must for an excellent medical transcriptionist.  Without typing speed it becomes very difficult for the medical transcriptionist to complete their targets and get the desired career results.
  • A good memory: Medical transcriptionists need to have a good memory. It is not possible for them to stop every now and then to look for things and yet be accurate.
  • Desire for continuous education: Medical transcriptionist need to continuously update themselves with new medications, new surgical instruments, and even new diseases. There are always new things to learn everyday in the medical transcription field. Hence, medical transcriptionist need to regularly update themselves with new revisions.
  • Learn new languages and accents: With the advancement in technology, medical transcriptionists need to prepare transcriptions for doctors residing in different regions and different accents. The more accustomed the medical transcriptionist is; the better changes of growth are available to them.

Medical transcriptionists need to have passion for words, curiosity for meaning and desire to continuously grow in this demanding field. A global medical transcription company will always recruit the best medical transcriptionists after evaluating the necessary skill-sets specified above.

About Mediscribes

Mediscribes, Inc. is one of the fastest growing Medical Transcription & document management systems providers in United States, based in Metro Louisville. Mediscribes is an ISO 9000-2001 certified company, rendering cost-effective consolidated transcription solutions to major hospitals, clinics, and other healthcare facilities in United States. Mediscribes is the most value-providing organization in the market today with a strong presence in America and offshore locations. The firm specializes in providing highly accurate transcription adhering to ADHI guidelines in unbeatable turnaround time with robust & proven document management system as its vantage point to its esteemed clientele.

Mediscribes provides end-to-end transcription solutions as its primary offering. For our customers, we focus on dictation systems, both ASP as well as enterprise level solutions, with the help of our most valued asset   ezVoiceIntelligence (ezVI), providing specialty-specific qualitative transcription along with a “whole nine yards” document management system. Mediscribes specializes in EMR data integration as well. Our data dispatch department is highly proficient in integrating transcribed reports into any type of EMR. Healthcare facilities that do not have EMR get the option to use our web-based file monitoring interface called eTranscribe for global access to their data. eTranscribe has special features of E-signing, E-faxing, auto-printing, and user-friendly document search criteria.

For additional information, please visit http://www.mediscribes.com

Medical Transcription and Coding demand will increase with ICD-10

5 Sep

Medical Coder and TranscriptionistThe world of medical transcription and medical coding is extensive and always changing. The change that has the medical field buzzing right now is the change from ICD-9 to ICD-10 (International Classification of Diseases – Version 10). Currently, health care facilities use ICD-9 for documentation and coding, but by October of 2014 every facility must abide by the new system. These new changes will increase the need for skilled medical transcription and medical coding. It will also bring these two jobs expertise closer and merge at some time in the future.

Why will demand for transcription and coding increase?

For healthcare employees already working as a medical transcriptionist or medical coder, they don’t need to worry about these changes affecting their chances of employment. The truth is that the need for these highly skilled workers will actually increase with the implementation of ICD-10.

One of the main reasons for the increase of work is that the new book of codes is a lot more specific than ICD-9. For instance, in ICD-9, the code for a burn on the left arm is the same code as a burn on the right arm. While this may not matter to the insurance company, it does matter to the treating physician, the patient and the transcription. There are not numerous new diseases in the new manual, but it will have over 70,000 codes listed. These are also going to be seven digits, instead of the five seen in the past. The increase in codes and length of codes will help the medical coder be more specific.

There is no substitute for an intelligent human mind, so the fear that medical transcription will be obsolete after the new implementation is unfounded. Both transcriptionist and coders will actually have to work harder and attend more training to become compliant. The new system may be confusing and overwhelming to those who have worked on ICD-9 for years. As these older employees leave the workforce, fresh new recruits will be needed.

Importance of Implementing Electronic Health Records (EHRs) from ICD-10 prospective

In order to be compliant with the new rules, healthcare facilities will find that having an efficient EHR (electronic health record) system in place first will be a huge benefit. There are still thousands of private practices that have not made the switch to electronic medical records, but this will hurt them when they must face compliance with the new coding regulations.

By implementing an easy to use and efficient EHR, the transition to ICD-10 will be a lot smoother. If a facility does not yet use computers for their records, they should consider doing this as soon as possible to be ready for the upcoming coding and documentation changes.

The reason an EHR is so important is because it helps streamline the coding process. It is much easier to use a search function on a computer than trying to pore through hundreds of pages in a patient’s chart to find information. To determine whether an injury was on the left or right side of the body, for example, the coder can simply search for this terminology within the patient’s electronic record. To find this information in a paper chart wastes hours of valuable time.

How will the New System Help Medical Transcription?

It may be true that the new system will mean less hours of transcribing work but it doesn’t appear transcription will be absolute. In fact, those that choose to stay in the field and learn ICD-10 coding will be rewarded with more hours than ever of transcribing work.

Because ICD-10 demands greater detail, physicians will have to begin giving greater detail in their records. This translates into more words for the transcription, which equals greater pay. Also, the increased need for transcription with coding expertise will mean better rewarding opportunities.