|
ZapCode |
||||
| • HCFA E&M Coding | ||||
| • Four Service Levels | ||||
| • Three Components | ||||
| • Proper Usage of ZapCode |
ZapCode Basics
HCFA Evaluation and Management Coding Assistant
This covers the methodology and operation of ZapCode.
See the complete current manual which is included in the ZapCode.zip file for all of the details of operation of the current version.
Click here to go to the ZapCode product page. or click here to see detailed ZapCode information.
Need more specific questions answered about ZapCode? Go to our FAQ'S section on our support page.
HCFA Evaluation and Coding Standards
ZapCode implements the 1997 HCFA Guidelines for Evaluation and Management Services.
You should be familiar with this document since it contains the complete set of rules. It is available at: http://www.hcfa.gov/medicare/mcarpti.htm
back to top
Four Service Levels
The goal of coding is to place your service into one of four levels:
1. Problem Focused
2. Expanded Problem Focused
3. Detailed
4. Comprehensive
ZapCode uses a scale of one through four to measure the level of service in component
and sub-component areas. A zero indicates no data. The scale measures of levels one to four correspond to the four
service levels. The final score is determined by the score in each of three component areas. Each of the component
areas has sub-components.
back to top
Three Components
There are three components that determine the service level:
1.History (sub-components: HPI, ROS, PFSH)
2.Examination
3.Medical Decision Making (sub-components: Number of Diagnoses, Data, Risk)
• Each Component is Scored 1-4
The sub-components of each component determine the score for that component.
• Each Sub-component is Scored 1-4
Each sub-component is scored on the range of 1-4 and the score for the component is based on the sub-component
score.
• History
The History component is made up of three sub-components (HPI, ROS, PFSH). The lowest sub-component score determines
the score for the History component.
• Exam
The number of exam elements determines the score for the Exam component. Exam elements are of two categories: major
(bulleted), and minor (non-bulleted). Only the major (bulleted) exam elements count towards the score.
• Decision Making
The Decision Making component is made up of three sub-components Options (Number of diagnoses), Data, and Risk).
The Options (Number of Diagnoses) screen asks you for the number of diagnoses and well as the difficulty of the diagnoses. If there is just one diagnosis in the category you should check the box under the column with the "1" at the top. If there is more than one diagnosis in this category, check the box under the "2+" heading.
The score for the Decision Making component is determined by the lowest of the top
two of the three sub-components (the lowest component is discarded and the lower of the remaining two sub-components
determines the score for the component).
back to top
Note on Proper Usage of ZapCode
ZapCode incorporates the logic HCFA E&M Guidelines as well as can be deduced from the document. However, there are areas of the guidelines that call for professional judgement. ZapCode will produce a suggestion for the proper code based on the information you enter. ZapCode is not a substitute for a thorough knowledge of coding requirements
All elements that are entered into ZapCode should be documented in the medical record so that the coding level can be supported in an audit.
HCFA and others apply various tests for coding compliance. These include proper documentation
to support individual charges as well as your overall coding pattern. Your compliance officer should conduct periodic
training and audits to verify compliance with the most current requirements.
back to top
For more information:
Mark H. Spohr, MD
Medical Informatics, Inc.
PO Box 6984
Tahoe City, CA 96145 USA
Phone: 1.530.583.3097
Fax: 1.530.583.3146
Email: Email Contact Form
More Questions? Email Contact Form
Copyright © 1999-2003 Medical Informatics, Inc.
