Medical Records Codeing

Medical Record Number: this field is used to enter the medical record number to receive information on the patient.

If the Medical Record Number is unknown click the Search Button to search the MPI (Master Patient Index) for the medical record number.

Once a valid account number is entered, information pertaining the patient will be displayed.

Admission Abstract Data

Admission Abstract Data

Medical Record Number: this field is used to enter the medical record number to receive information on the patient.

If the Medical Record Number is unknown click the Search Button to search the MPI (Master Patient Index) for the medical record number.

The screen will display the Patient's Name, FSC, Medical Record Number, Admission Type, Admitted From, Re-Admission, Admit Doctor, Referring Doctor, UPIN Referring Doctor, Consulting Doctors 1, 2, 3 and 4, Condition Code, Visitors Code, Diet Code, Date of Onset, and Expected Discharge Date.

Discharge Abstract Data

Discharge Abstract Data

Medical Record Number: this field is used to enter the medical record number to receive information on the patient.

If the Medical Record Number is unknown click the Search Button to search the MPI (Master Patient Index) for the medical record number.

The screen will display the Patient's Name, FSC, UB Billing Code, Discharge Doctor, Infections Code, Disposition Code, Status Code, Autopsy Code, Fetal Death Code, Surgery Type Code, Discharge Service Code, and Number of Consultants, Birth Weight, and Abstract Data Field 1, 2, 3, 4 and 5.M-R-N: this field is used to enter the medical record number to receive information on the patient.

Coded Abstract Data

Coded Abstract Data

Medical Record Number: this field is used to enter the medical record number to receive information on the patient.

If the Medical Record Number is unknown click the Search Button to search the MPI (Master Patient Index) for the medical record number.

The screen will display the Patient Name, Diagnosis Description, Admission Diagnosis, Concurrent Diagnosis, Principal Diagnosis, Surgical Type Code, Operative Description and Primary OP Procedure.

Data Entry for Diagnosis

Data Entry for Operative Codes

The Medical Necessity Check Button will check all CPT/HCPCS code based on the diagnosis for medical necessity.