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Understanding Risk of Mortality (ROM) in Medical Coding
What is Risk of Mortality (ROM)? Risk of Mortality (ROM) in medical coding is a clinical severity measure used in healthcare coding and reporting that estimates the likelihood a patient will die during a hospital stay. ROM is typically assigned using coding systems...
Understanding Severity of Illness (SOI) in Medical Coding
What is Severity of Illness (SOI)? Severity of Illness (SOI) in medical coding is a classification system used in healthcare reporting that measures the extent of a patient’s illness. It reflects how sick the patient is and how much hospital resources may be required...
What Is MCC in Medical Coding
Understanding MCC and How It's Used In medical coding, MCC stands for Major Complication or Comorbidity. It is a classification used in the ICD-10-CM and MS-DRG (Medicare Severity Diagnosis-Related Group) systems. MCCs represent conditions that are severe and...
How to Approach a Long Medical Coding Exam Scenario
Read the Case Carefully Skim the entire scenario once to understand the big picture (inpatient, outpatient, ED, surgical, etc.). Underline or highlight key clinical details: Primary diagnosis Secondary diagnoses/comorbidities Procedures performed Patient status (new...
What is Pro Fee Coding
Pro fee coding, short for professional fee coding, refers to the process of assigning medical codes to professional services provided by physicians and other qualified healthcare professionals. Pro fee coding focuses on capturing and billing for the provider’s...
What Is Medical Necessity in Medical Coding & Billing
What Is Medical Necessity in Medical Coding & Billing? Medical necessity is a cornerstone of accurate medical coding and billing. It determines whether a service, procedure, or supply is reasonable, necessary, and appropriate based on a patient’s medical...
What Is an Encoder in Medical Coding
What Is an Encoder in Medical Coding? An encoder is a specialized software tool used by medical coders to streamline the coding process by helping identify the correct diagnosis (ICD-10-CM), procedure (CPT/HCPCS), and modifier codes. Encoders often integrate official...
Medical Coding Audits
Medical Coding Audits: Guidelines & Tips for Compliance and Accuracy Medical coding audits are essential for maintaining compliance, ensuring accurate reimbursement, and reducing the risk of denials or legal penalties. Whether you're a coding professional,...
Medical Coding Compliance
Medical Coding Compliance Guidelines & Tips for Medical Coding & Billing Maintaining billing and medical coding compliance is critical for preventing audits, avoiding penalties, and ensuring timely reimbursement. Healthcare organizations, providers, and coders...