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45 Cards in this Set

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ICD-9
International Classification of Diseases, 9th Revision.
Instituted by the World Health Organizaion.
17,000 codes
ICD-10
We will transition in 2013.
More specific
68,000 codes
IDC-9-CM
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.
Hearing Loss ICD-9-CM code
389
Sensorineural Hearing Loss, Perceptive hearing loss or deafness ICD-9-CM code
389.1
Sensory hearing loss bilateral ICD-9-CM code
389.11
Neural hearing loss bilateral ICD-9-CM code
389.12
Sensorineural hearing loss bilateral ICD-9-CM code
389.18
V Codes
Secondary diagnosis codes. Do not describe disease state. Affects patient care.
Repair/modification of HA V Code
V5014
Person with feared complaint in whom not dx was made V Code
V655
Family hx of hearing loss V Code
V192
Procedure Codes
Current procedural terminology= CPT. Owned by the American Medical Association. Reflect procedures you perform. Mechanism to bill for services: tracking and documentation.
Basic Comprehensive Audiometry. Pure tone air, bone, and speech CPT Code
92557
Pure tone air and bone conduction CPT Code
92553
Speech threshold/discrimination CPT Code
92556
Tympanometry only CPT Code
92567
Tymp and ART only CPT Code
92550
Tymp, ART, ARD CPT Code
92570
HCPCS Codes
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.
Monaural vs. Binaural HCPCS
V5256 vs. V5260
Digitally Programmable vs. Digital (BTE) HCPCS
V5247 vs. V5257
Ear mold, not disposable, any type HCPCS
V5264
HA Supply/Accessory HCPCS
V5267
Batteries HCPCS
V5266
Assistive Listening Device, NOS HCPCS
V5274
What codes must be included?
Each invoice must include ICD-9-CM.
Must include procedure code(s) CPT and/or HCPCS.
SOAP Note
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.
Progress Note
Simple and condensed. Patient presenting complaint. Procedures. Refresh memory regarding patient particulars. Follow-up.
Progress Note - SDSU
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.
Treatment Plan
Set goals and objectives. Specify strategies for specific outcome. Can be included w/ in report. May be summarized in a progress note.
Oral Report
Patient, referral source, colleagues, formal presentation.
Purpose of Reports
Document professional opinion for patient complaints. Summarize results of testing. Recommend further testing. Make recommendation for follow-up.
Writing Reports
Mostly intuitive: no step-by-step, transitioning to "templates."
Situational: into to include/delete, style for your audience, synthesize date for purpose.
Diagnostic Reports - History
Referral source. Presenting complaint. Previous testing. Medical/hearing/hearing aid history. Verify information on case history.
Diagnostic Reports - Results
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.
Diagnostic Report - Impressions & Recommendations
Summarize results. Compare results to any previous test results. Recommendations: consider current test results, medical necessity.
SOAP - Subjective
Relevant patient complaints. History. Medical/otologic data. Subjective observations: informant providing information, patient as a poor historian.
SOAP - Objective
Procedures performed. Results. Conditions present during testing. Provide an understanding of the approach taken for the assessment of the presenting complaint.
SOAP - Assessment
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.
SOAP - Plan
Recommendations. Can be the "next steps" for the patient to follow. Document patient education here.
BTE Hearing Aids
Receiver in the hearing aid. Standard ear hook. Standard tubing: inside diameter. Custom-made earmold.
RITE Hearing Aids
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).
Open Hearing Aid
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.
Gain Across Frequencies
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.