Your Hospital Medical Record Available Here
Posted on Friday, June 27th, 2014
HEALTH INFORMATION SERVICES
Medical Records
This department maintains the medical record of your hospital stay or visit to the emergency room, x-ray, laboratory, respiratory, or therapy departments for tests or treatment.
The record is available for your inspection or copying or transmittal to another health care provider. It is in electronic format.
Medical Coding
Skilled medical coders in the department act on data in the patient’s medical record early in the billing process.
They abstract information, such as the doctor’s initial diagnosis and the procedures performed, and assign the correct health industry codes.
The codes give the hospital’s medical billers the information they need to successfully process a claim for reimbursement by the patient’s insurance company.
“The coder must be very familiar with human anatomy and medical terminology in order to properly classify and support a diagnosis,” said Linda Dixon, department manager.
“For instance, if pneumonia is the initial diagnosis, does the medical record show a specific test to back that up? If so, was the result a bacterium, a virus, or unspecified? If it was bacterial, was it staph, strep, or other specified organism? Different code numbers apply in each of these cases.”
Vickie Preast, Medical Coder
Has seven years with
Mercy Health/Love County
as the medical coder for
outpatient, emergency
room, and ambulance cases.
In the past, has used her
Mercy Health/Love County
as the medical coder for
outpatient, emergency
room, and ambulance cases.
In the past, has used her
Murray State College degree
in medical office administration
to work for a clinic and a
home health agency, and
has performed patient care as a
hospital CNA. She takes
continuing education
in coding to keep up with
changes in classification.
“I enjoy the research of it.
in medical office administration
to work for a clinic and a
home health agency, and
has performed patient care as a
hospital CNA. She takes
continuing education
in coding to keep up with
changes in classification.
“I enjoy the research of it.
Dr. O’Connor called us ‘the
medical record detective
agency.’”
medical record detective
agency.’”