Knowledge Base

The coder record provides a split screen interface whereby  all applicable diagnosis and procedural codes can be viewed and modified on the left panel. Supporting clinical documentation is available for view on the right panel.

The interface provides several functionalities:

1. An ability to view and add ICD-10 diagnosis codes
   1. Clicking the “+ ICD-10 Code” interface enables users to search for and populate additional codes
   2. Coders can respond to each code
      1. Accept
      2. Reject
         1. If reject is chosen a rejection reason must be specified:
            1. Missing MEAT/Document
            2. Wrong Code
            3. Recommended Code
   3. Comments can be added at the code level within this view
   4. Coders can choose to tag the code to a specific type, including:
      1. Previously Reported
      2. Additional Diagnosis
      3. Suspect Diagnosis
2. An ability to view and add CPT procedural codes
   1. Clicking the “+ CPT Code” interface enables users to search for and populate additional codes
   2. Coders can respond to each code
      1. Accept
      2. Reject
         1. If reject is chosen a rejection reason must be specified:
            1. Missing MEAT/Document
            2. Wrong Code
            3. Recommended Code
   3. Comments can be added at the code level within this view
3. If at any time while using the tool the user wishes to refer to the configured coding guidelines, the entire library of enabled guidelines can be accessed by clicking the “Coding Guidelines” button 
4. If the encounter was generated based upon a file upload, the coder can toggle between the generated clinical documentation from the transcription process and the original uploaded clinical document by clicking the “Toggle Original” option
5. If the encounter contained incorrect codes or requires additional feedback from the provider, the coder can electronically return the encounter to the provider by choosing to click the “Return Feedback” button
6. If the coder is ready to complete the review, they may choose to click “Accept and Submit”. This option moves the encounter to the coding complete status
   1. Any diagnosis of type Additional Diagnosis or Suspect Diagnosis that have a provider response of Agree are updated in health history to the diagnosis type of Previously Reported once the encounter moves to coding complete status. The current encounter maintains existing status but subsequent new encounters will pull in diagnosis from history and show it as type Previously Reported. Codes with provider response of rejected will remain the same type in health history.
   2. Any diagnosis added by the coder that was not documented by the provider, has a coder response of rejected and diagnosis type of Suspect Diagnosis will be added to health history as a suspect diagnosis for subsequent future encounters when encounter is moved to coding complete status
7. The history panel provides a historical log of all individuals who touched the encounter