Amadokhumenti wezokwelapha kubalulekile emisebenzini ye- coder yezokwelapha . Omunye wemithwalo yemfanelo enkulu yekhodi yezokwelapha ukuguqula ulwazi kumarekhodi wezokwelapha ukuxilongwa kanye nenqubo yamakhodi wokukhokha . Lapho ubhala amanothi odokotela, kubalulekile ukuthi ungalokothi ucabange. Uma ungaqiniseki noma ungaqondakali, njalo uthole ukucaciswa kudokotela.
Kunezinhlobo ezimbili zamadokhumenti odokotela abasiza ikhodi yezokwelapha ekukhokhweni kwamakhodi ama-office amanothi namanothi okusebenza.
- Amanothi ehhovisi anezizathu zesiguli sokuvakashelwa, izimpawu, izifo kanye nokuxilongwa, ukuthola okudokotela, uhlelo lwezokwelapha, kanye nokuhlelwa kokulandela.
- Amanothi okusebenza ahlanganisa ukuxilongwa kwangaphambili, ukuxilongwa kwe-postoperative, izinsizakalo nezinqubo ezenziwe, kanye nencazelo yezinto ezenzeka ngaphambili, ngesikhathi, nangemva kwenqubo.
Lapho uchaza amadokhumenti, qiniseka ukuthi wonke amanothi alotshwe udokotela asekela ukuxilongwa nezinqubo. Futhi, qinisekisa ukuthi ukuxilongwa kunikeza isidingo sezokwelapha ngezinqubo ezibalwe kumanothi.
Nika amakhodi we-ICD-10 namakhodi we-CPT
I-coder yezokwelapha kufanele inikeze amakhodi ukuxilongwa kanye nezinqubo ezibhalwe kumarekhodi eziguli.
Amakhodi Wokuthola
Amakhodi wokuxilonga abelwa kusukela ku-International Classification of Diseases (ICD). Uhlelo lwamanje yi- ICD-10 . I-ICD-10 yasungulwa yi-Centers for Medicare neMediicaid Services (CMS) ngo-Okthoba 1, 2015, esikhundleni se-ICD-9.
Izinsizakalo ezinikezwe ngaphambi kuka-Okthoba 1, 2015, kumele zikhokhiswe ngamakhodi we-ICD-9 ngisho noma izinsizakalo zingakhokhiswa kuze kuphele u-Okthoba 1, 2015. Izinsizakalo ezinikeziwe ngemuva kokuqaliswa kwe-ICD-10 ngo-Okthoba 1, 2015, kumele zikhokhiswe nge-ICD -10 amakhodi.
Amakhodi Wokusebenza
Amakhodi enqubo abelwe kusukela encwadini ye-Current Procedural Terminology (CPT) njengoba kunqunywe yi-American Medical Association (AMA).
Incwadi ye-CPT ibhala amakhodi we- CPT , inqubo ehambisanayo kanye nezincazelo ezisetshenziswa odokotela, izibhedlela eziphulukisayo, nezikhungo zokuhlinzeka ngezidakamizwa (ASC). Izinqubo zokugula izibhedlela azibhalwanga encwadini ye-CPT. Lawa makhodi atholakala encwadini ye-ICD-10-PCS, esikhundleni se-ICD-9 Volume 3.
Hlala Usuku Ngezinkombandlela Zokukhokha
- Vakashela iwebhusayithi ye-AMA. Isayithi linikeza okungeziwe, ukuphelelwa yisikhathi, izibuyekezo, kanye nokubuyekezwa kumbhalo wokubhalisa. I-website ye-AMA isiza amakhodi ekugcineni ulwazi lwabo lwamakhono kanye namakhono okuvuselela, bahlanganyele ezenzakalweni ezisiza ukuthuthukisa nokugcina ikhono lokubhala ikhodi, bajwayele neziqondiso nemithetho, futhi bathole ulwazi lokuthuthukisa ikhwalithi yomsebenzi wabo. U-AHIMA ne-AAPC nabo banamawebhusayithi ahlinzeka ngolwazi olutholakala ngesikhathi esifanele, oluningiliziwe nolusesikhathini samanje kuma-coder yezokwelapha njalo.
- Thola izibuyekezo zekhodi ye-CMS. I-CMS ishicilela izibuyekezo kwiwebhusayithi ye-CMS njalo ngonyaka. Ibuye inikeze ngezinsiza ezihlinzeka ngemithombo, isimiso nemithethonqubo, kanye nolwazi oluthize lweMedare. Iziguli zeMedare nazo ziwumthombo omuhle kakhulu wokushintsha izinguquko ezivamile. Ama-coders angayibhalisela i-listervs.
- Inethiwekhi namanye amakhodi. Ukwenza ikhodi kuyindawo enkulu kakhulu, ikhodi eyodwa ayikwazi ukwazi konke okumele ukwazi ngokubhala ikhodi. Ngezinye izikhathi ama-coders agijimela ezimweni abadinga usizo olwengeziwe. Ama-coders angaba yisisetshenziswa esikhulu, ngokuvamile esisetshenziswa kangcono, omunye komunye. Ngenkathi ulwazi olubalulekile lubalulekile, kubalulekile ukuthi uqaphele ukuthi isiphi iseluleko noma usizo olwamukelweyo. Izinkundla zekhodi yindawo eyodwa yokuhlala kude. Noma ubani angaphendula imibuzo emibhokisini yokubhala ikhodi engabangela ikhowudi ukuthi iphule imithetho yokubhala ikhodi.
- Funda imiyalo ye-CPT. Imiyalo ekhompyutheni yekhodi ye-CPT yilapho ukusiza amakhodi wonke ulwazi olufanele mayelana nokubhala ikhodi njengokuthi ungathola kanjani amakhodi, izigaba zamakhodi, izincazelo zamakhodi, yiziphi amakhodi angakhokhiswa ndawonye nokuthi yiziphi amakhodi okufanele akhokhiswe yedwa.