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Anesthesia Coding Alert

Documentation:

Nail Down Common Acronyms to Code More Accurately

Published on Wed Sep 07, 2011

Test yourself to see how well you interpret these abbreviations. If the charts you code from sometimes look like alphabet soup because of specialized acronyms or abbreviations your providers use, it's time to brush up on some common terms to help improve your coding. Here's why: When the physician documents a chart, he doesn't always have time to spell out phrases such as "past history" (PH) and "present illness" (PI), but knowing which is which can make a tremendous difference in the accuracy of your charts. If you code a chart assuming that the patient currently suffers from every condition listed as "PH," you'll be coding the wrong diagnoses for the current illness.Does 'TKA' Mean Visualizing or Replacing?The physician documents "TKA" in the patient' chart, which could stand for "total knee arthroplasty" or "total knee arthroscopy." During arthroplasty, the surgeon repairs or replaces a joint. During arthroscopy, by contrast, the [...]
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