Aud 721 Clinical Methods

Front 1

ICD-9

Back 1

International Classification of Diseases, 9th Revision.
Instituted by the World Health Organizaion.
17,000 codes

Front 2

ICD-10

Back 2

We will transition in 2013.
More specific
68,000 codes

Front 3

IDC-9-CM

Back 3

Clinically modified for use in the United States. Not developed by WHO.
Disease and Diagnosis Code: Patient signs and symptoms, complaints, outcomes of procedure results.
5-digit code for more specificity.

Front 4

Hearing Loss ICD-9-CM code

Back 4

389

Front 5

Sensorineural Hearing Loss, Perceptive hearing loss or deafness ICD-9-CM code

Back 5

389.1

Front 6

Sensory hearing loss bilateral ICD-9-CM code

Back 6

389.11

Front 7

Neural hearing loss bilateral ICD-9-CM code

Back 7

389.12

Front 8

Sensorineural hearing loss bilateral ICD-9-CM code

Back 8

389.18

Front 9

V Codes

Back 9

Secondary diagnosis codes. Do not describe disease state. Affects patient care.

Front 10

Repair/modification of HA V Code

Back 10

V5014

Front 11

Person with feared complaint in whom not dx was made V Code

Back 11

V655

Front 12

Family hx of hearing loss V Code

Back 12

V192

Front 13

Procedure Codes

Back 13

Current procedural terminology= CPT. Owned by the American Medical Association. Reflect procedures you perform. Mechanism to bill for services: tracking and documentation.

Front 14

Basic Comprehensive Audiometry. Pure tone air, bone, and speech CPT Code

Back 14

92557

Front 15

Pure tone air and bone conduction CPT Code

Back 15

92553

Front 16

Speech threshold/discrimination CPT Code

Back 16

92556

Front 17

Tympanometry only CPT Code

Back 17

92567

Front 18

Tymp and ART only CPT Code

Back 18

92550

Front 19

Tymp, ART, ARD CPT Code

Back 19

92570

Front 20

HCPCS Codes

Back 20

Healthcare Common Procedure Coding System. Developed by Center for Medicare and Medicaid Management System (CMS). Audiology uses Level II Codes: codes that do not cave CPTs, uses alphanumeric codes. Codes for monaural vs. binaural, type of technology, specific devices, accessories, ALDs.

Front 21

Monaural vs. Binaural HCPCS

Back 21

V5256 vs. V5260

Front 22

Digitally Programmable vs. Digital (BTE) HCPCS

Back 22

V5247 vs. V5257

Front 23

Ear mold, not disposable, any type HCPCS

Back 23

V5264

Front 24

HA Supply/Accessory HCPCS

Back 24

V5267

Front 25

Batteries HCPCS

Back 25

V5266

Front 26

Assistive Listening Device, NOS HCPCS

Back 26

V5274

Front 27

What codes must be included?

Back 27

Each invoice must include ICD-9-CM.
Must include procedure code(s) CPT and/or HCPCS.

Front 28

SOAP Note

Back 28

Subjective, Objective, Assessment, Plan. Or History, Results, Recommendations.
Condensed version of the report. May be only documentation of the encounter. May have to limit information based on document space requirements. Add an addendum if allowed within the EMR system. Include a full report with detailed information.

Front 29

Progress Note

Back 29

Simple and condensed. Patient presenting complaint. Procedures. Refresh memory regarding patient particulars. Follow-up.

Front 30

Progress Note - SDSU

Back 30

Always include what patient paid. If patient owes money: document and highlight. Follow-up: RTC, call patient to p/u HA, appt made when HA returns.

Front 31

Treatment Plan

Back 31

Set goals and objectives. Specify strategies for specific outcome. Can be included w/ in report. May be summarized in a progress note.

Front 32

Oral Report

Back 32

Patient, referral source, colleagues, formal presentation.

Front 33

Purpose of Reports

Back 33

Document professional opinion for patient complaints. Summarize results of testing. Recommend further testing. Make recommendation for follow-up.

Front 34

Writing Reports

Back 34

Mostly intuitive: no step-by-step, transitioning to "templates."
Situational: into to include/delete, style for your audience, synthesize date for purpose.

Front 35

Diagnostic Reports - History

Back 35

Referral source. Presenting complaint. Previous testing. Medical/hearing/hearing aid history. Verify information on case history.

Front 36

Diagnostic Reports - Results

Back 36

Reliability. Testing procedures: report modifications to standard testing procedure. Reporting all test results: include tests not associated with the "normal" test battery, unexpected results, discrepancies in results.

Front 37

Diagnostic Report - Impressions & Recommendations

Back 37

Summarize results. Compare results to any previous test results. Recommendations: consider current test results, medical necessity.

Front 38

SOAP - Subjective

Back 38

Relevant patient complaints. History. Medical/otologic data. Subjective observations: informant providing information, patient as a poor historian.

Front 39

SOAP - Objective

Back 39

Procedures performed. Results. Conditions present during testing. Provide an understanding of the approach taken for the assessment of the presenting complaint.

Front 40

SOAP - Assessment

Back 40

Most important section of the SOAP. May be the only line that is read. Often combine O and A section to make the Impression section on the audiological report.

Front 41

SOAP - Plan

Back 41

Recommendations. Can be the "next steps" for the patient to follow. Document patient education here.

Front 42

BTE Hearing Aids

Back 42

Receiver in the hearing aid. Standard ear hook. Standard tubing: inside diameter. Custom-made earmold.

Front 43

RITE Hearing Aids

Back 43

Receiver in the canal vs. in the hearing aid. Open or closed dome. Frequency range: full range with closed dome, restricted range with open dome (no low frequencies).

Front 44

Open Hearing Aid

Back 44

Slim tube open fitting. Receiver in the hearing aid. Open or closed/custom dome. Can use conventional earhook or slim tube on same device. Must choose correct tube in the software.

Front 45

Gain Across Frequencies

Back 45

Closed gives the most gain across all frequencies. Earmold with large vent/open dome reduces available low frequency gain. Open fitting (slim tube) provides no gain below about 1500 Hz. It is acoustically impossible to pass the low frequencies through the slim tube.