general surgery

Medical Coding
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Medical Coding
General surgery involves performing a surgical specialty with the focus on contents of the abdomen which includes pancreas, stomach, and colon among others. It may extend to surgical coding where the focus is the surgical subspecialty. Certified coders must be involved in the performance of such a medical exercise for best results. The involvement of medical coding presents an opportunity for performing bilateral surgeries among other multiple surgical procedures which must frequently be performed. The role of this essay is to provide the documentation for general surgery, determination of success for coders, and the need for having up to date records in the entire coding process.
Documentation for General Surgery
Documentation for general surgery presents a combination of medical records with a chronological outline of the course of treatment for the patient. There should be the high quality of reports obtained from medical records without any element of sub-optimality. In essence, any deficiency in the source documents must be eliminated. Achieving this is possible through the aspect of documenting relevant data relating to the subject of medical coding. The use of general surgery documentation is an appropriate technique for coding, and this is used in therapeutic conditions, diagnostic, lesion excision, biopsy, diverting ileostomy, “Hyperthermic Intraperitoneal Chemotherapy” coding (HIPEC), and trauma coding (“2017 Mastering General Surgery CPT© Coding”, 2016).

Specific examples of documentation in general surgery include inpatient service requirements, observation service requirements, concurrent care requirements, critical care service requirements, among others.

Success of Coders
There are specific ways which coders can ensure that they become successful when coding under general surgery. There is the need to provide a general description of the condition under surgery with an element of precision. The words used in the documentation must incorporate appropriate technology in explaining the condition of surgery to another physician. Through this approach, there is an assurance of an accurate code assignment which leads to a successful operation. There is the need for documentation of laterality, where appropriate (Eramo, 2013). The meaning of this notion is that a general surgeon operating a diseased organ must document laterality. Similarly, success can be realized when coders document the occurrence of any manifestations. The incorporation of any manifestations necessitates the aspect of a clear documentation making coders allocates the appropriate code. The combination of the aspect of appropriate manifestations and laterality contributes largely to the overall success when coding general surgery.
It is important to ensure that the process of documentation is up to date. Similarly, notes provided to nurses should be complete. The importance of this is to ensure that the current recommended medical practices are utilized while performing any work of general surgery for best results. The use of complete notes provided by nurses is an assurance that there is the presence of the relevant professional knowledge required in any work of surgery.
The aspect of providing relevant documentation on the subject of medical coding is an important consideration in the performance of general surgery. The documentation involved in general surgery may include inpatient service requirements, observation service requirements, and concurrent care requirements among others. The aspect of documentations presents the assurance of updated medical records which outline the particular course for the treatment of patients. The success of coders is determined by the level of technology they use, documentation of laterality, taking note of any manifestations, and the allocation of appropriate code to a particular case of surgery. An updated documentation must also be provided to ensure that a particular case of surgery in being handled by the application of recommended practices in the field of medical surgery.

References
2017 Mastering General Surgery CPT© Coding. (2016). American College of Surgeons. Retrieved 22 November 2016, from https://www.facs.org/advocacy/practmanagement/workshops/fridayEramo, L. (2013). 4 ICD-10 Tips for General Surgeons. Retrieved from http://gettingpaid.kareo.com/gettingpaid/2013/12/4-icd-10-tips-for-general-surgeons/