MEDICAL CODING PROBLEM

[Steve Verno]

??

[Cheryl]

I have to work on software for people who code inpatient visits for a hospital.  I need to find out what is happening in the real world.  For each inpatient visit that is discharged, it checks to see if either of the following two conditions, A and B, is true.  Each condition, if true, produces something that needs to be coded.  What is happening?

A. If the operative notes, cardio and pathology reports are done, then create a document to be coded.

B. If the balance is less than or equal to zero, then create a document to be coded.

1. What are these documents being created?  What are they used for?

2. Furthermore, there are two types of coders: onsite and offsite.  One type codes the documents produced by (A) and the other type codes the documents produced by (B).  Is there a reason that people who are onsite or offsite would code that particular kind of document, (A) or (B)?

3. They say there is a problem in that a discharge can have both documents and two different coders get the documents.  Is that a rule, that it is better if the same person codes both of these documents when they both exist on one discharge?

Thanks for any answers or explanations.