Gail is a Medical Coder at the Rehabilitation Hospital of Wisconsin. Working out of the hospital in Waukesha, Gail’s main role as a coder is to analyze clinical statements written by the staff doctors and to then assign standard codes using a classification system.
Transcript
I'm Gail Persich and I'm a medical coder. Basically you are reading physician documentation and you are pulling out any diagnosis that can be coded to tell a story of a patient. So I basically read through all the documentation and code what needs to be coded for the insurance company so they understand what is going on with the patient. Well there're templates that the physicians will add in there every time they, be in inpatient hospital. They see the patient throughout the day. Anytime that they see the patient they'll add notes and I would go through daily on all their notes at discharge and just, if they're there two weeks, I'm looking at every, all the documentation that the physician has added for that patient. I would run down that section that pretty much gives me the information of why the patient was in need of acute care hospital and why are they being, why are they now coming to a rehabilitation hospital. And then I would have to read that, find the etiology diagnosis, what is causing that patient to come to us now and that diagnosis is very important because that kinda gives us an idea of how many days that patient can stay there. How long is it gonna take to rehab them before they can go home and take care of themselves. The rest of the information is just pretty much a progress note. All the information will be in there from that doctor and then everyday or every visit when they walk into that patient's room they will add on to that section, that body, of just more information. Maybe another diagnosis may come up mid-week because they found something new. There's a big book of codes. So when I was in school at WCTC we coded from that book. Now in the real world we use 3M, it's virtual. It's like coding you put in all the information and it kinda walks you through. You can be very specific with it and then it, at the end, it will show that code.
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