POCC is the coding of medical procedures and services and the patient’s condition –at the “Point-of-Care” – up close, where the action is. In other words, POCC is performed by an RN who either provided the care or assisted the physician in providing the care. This can be in an inpatient or outpatient setting, in the physician’s office, in the Emergency Department, in the cardiac catheterization lab – anywhere patient care is being delivered.
Point of Care Coding has been demonstrated to alleviate issues such as lost charges – either the service or supply was never documented in the patient’s record – or it was missed during the clerical coding phase in medical records. It has also eliminated incorrect coding when applied by a Certified RN-Coder who has completed a 125-hour continuing education program.
Point of Care Coding performed by a Certified RN-Coder assures that everything is documented correctly – then he or she applies the correct procedure and supply codes, as well as the diagnosis code(s) (or signs and symptoms) for the patient’s condition.
In the fast-paced Emergency Department, for example, a Certified RN-Coder who has an ED nursing background, will be the best staff member to assure everything is documented and then do the coding of it BEFORE the chart leaves the unit – or in EHR terms – BEFORE the chart is signed off and closed. However, to be effective, this person must be able to provide ONLY coding and documentation functions, rather than nursing functions.
A Certified RN-Coder would also be able to assess other departmental coding related to the patient’s care, such as laboratory testing results, imaging reports, pharmaceutical orders and administration, to be sure there is a cohesive and correct “picture” of the patient’s care.
“This is what we did (CPT procedure coding, HCPCS supply coding).” And “This is why we did it.,” (ICD9 coding of conditions, Present on Admission, signs and symptoms), is how Joyce Thomas, a healthcare administrator for over 30 years primarily in medical practice management, describes the coding process for nurses and physicians.
“When a Certified RN-Coder checks the documentation and performs the coding process BEFORE the patient leaves the unit – correct coding happens MOST of the time, eliminating the need for expensive re-billing, appeals, etc.” states Thomas. “Third party reimbursement and compliance with state and federal regulations is assured.”
Through the RN-Coder Network, Joyce Thomas has been training Registered Nurses, physicians and other clinical professionals in correct coding and how to perform chart reviews for a wide variety of audits since 2001. Since 2008 the programs have been available online 24/7, no time limits, self-paced. Continuing education credit for licensing is provided by SMRS, an approved California Board of Registered Nursing CE provider, CEP# 13482. Most state nursing and medical boards accept CE credit from other boards.
“In the first few years of ICD10 coding, Certified RN-Coders will be indispensable for assuring complete data collection,” states Thomas. “There should be one of every shift and on every unit, to be sure everything goes well for revenue integrity and optimal reimbursement.” Remember, your facility or medical practice is building it’s future fee profile with every payer – and Point of Care Coding will assure more accuracy, with a correct fee profile as the result.
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