-: I'm Gail Persich and I'm a medical coder.
Basically you are reading physician documentation
and you are pulling out any diagnosis
that can be coded to tell a story of a patient.
So I basically read through all the documentation
and code what needs to be coded for the insurance company
so they understand what is going on with the patient.
Well there're templates that the physicians
will add in there every time they,
be in inpatient hospital.
They see the patient throughout the day.
Anytime that they see the patient
they'll add notes and I would go through daily
on all their notes at discharge and just,
if they're there two weeks, I'm looking at every,
all the documentation that the physician
has added for that patient.
I would run down that section that pretty much gives me
the information of why the patient was in need
of acute care hospital and why are they being,
why are they now coming to a rehabilitation hospital.
And then I would have to read that,
find the etiology diagnosis, what is causing that patient
to come to us now and that diagnosis
is very important because that kinda gives us
an idea of how many days that patient can stay there.
How long is it gonna take to rehab them
before they can go home and take care of themselves.
The rest of the information is just
pretty much a progress note.
All the information will be in there
from that doctor and then everyday or every visit
when they walk into that patient's room
they will add on to that section, that body,
of just more information.
Maybe another diagnosis may come up mid-week
because they found something new.
There's a big book of codes.
So when I was in school at WCTC we coded from that book.
Now in the real world we use 3M, it's virtual.
It's like coding you put in all the information
and it kinda walks you through.
You can be very specific with it and then it,
at the end, it will show that code.