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Have a coding or transcription question? Get an expert answer by sending an e-mail to edit@gvpub.com.

This month’s selection:
According to pregnancy coding guidelines, if the condition being treated doesn't affect or isn't affected by the pregnancy, the physician must specifically document this information in the medical record. If the pregnancy does not seem to impact the visit but the provider does not state that in the documentation, can you code it as incidental? How do you code it?

Janice Randall-Payne, BS, CPC-I, CPC-H, CPC, CCS-P, PCS, CPAR
Navy Medicine East
Portsmouth, Virginia

Coding has to follow guidelines and include the required information in the documentation. If the provider does not document the information, it would be inappropriate to assume that the patient's pregnancy is incidental to the condition or treatment. You should go to the provider and ask him or her whether a causal relationship exists between the condition or treatment and the patient's pregnant state before applying a code.

— Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC, is CEU vendor department manager for AAPC.
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Editor's E-Note
Branding is everywhere these days. For example, tune in to a baseball game—from Fill in the Blank Bank Field, no doubt—and you’re bound to hear the seventh-inning stretch associated with the work of the local chiropractor and pitching changes sponsored by the manufacturers of baby diapers.

Who wouldn’t want to be associated with the national pastime? The banking conglomerate, once viewed as impenetrable, is now seen as friendly, quaint, and old fashioned.

In an attempt to redo its image, medical transcriptionists have been rebranded as documentation specialists by a leading industry association. This month’s E-News Exclusive examines the ramifications of making such a move.

Lee DeOrio, editor
E-News Exclusives
Medical Transcription: Rebranding the Profession
By Kathy Nicholls, CMT, AHDI-F

Enter the medical transcription profession and you will find yourself constantly reinventing yourself, updating your skills, and dealing with change. It’s the nature of the industry. Today, the rapid advancement of technology makes this even more true than it was 10 years ago.

In an effort to rebrand the profession, the National Leadership Board of the Association for Healthcare Documentation Integrity (AHDI) voted earlier this year to change the name of the profession from medical transcriptionist (MT) to healthcare documentation specialist. In part, the press release from Linda Brady, AHDI CEO, states:

“As our roles in healthcare documentation evolve and the range of services medical transcriptionists are able to offer broaden, a natural next step is to position ourselves for these changing roles. This can take shape in a variety of ways, and as your professional association, we are promoting a new umbrella title—healthcare documentation specialists—to help shift perceptions in the marketplace on the value, skills, and body of knowledge we bring to the table. In essence, we're encouraging a rebranding of the medical transcriptionist title to help shed any erroneous perceptions and to promote our vital role in preserving the integrity of healthcare documentation among hospital administrators, physicians, clinicians, EHR vendors, employers, and consumers.”

Full Story »
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Tech & Tools
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My Place History App
My Place History links public health information with the users’ environmental experience, providing a greater understanding of how their local environment can affect their health. Using US street addresses to create and maintain a personal place history, the app allows users to gather general information about their proximity to environmental hazards or exposures and helps them map their lifetime environmental exposures. It is available for iPhones and iPads from the Apple iTunes Store. Learn more »

LowestMed Mobile App
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SweetBeat iPhone App
SweetBeat helps users effectively manage fitness and stress and plan workouts based on vital signs rather than a canned workout schedule. Using a compatible heart rate monitor, SweetBeat measures the user’s heart rate variability. When a person’s stress rises, heart rate variability falls. It can detect overtraining and objectively measure the body’s response to each workout. Users can see their heart rate variability levels in real time, enabling them to manage stress or vary their workouts. When a user’s stress rises above the user-determined threshold, a “relax” screen appears with a breath pacer. Simply by breathing deeply and regularly, users can balance their system, returning to a more relaxed state. The iPhone app is available from the Apple iTunes Store. Learn more »
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