Coding Rules and Requirements

Health Authority Of Abu Dhabi

(HAAD) Update
 HAAD CIRCULAR NO. (DG 17/17)
Dated 17/05/2017

Subject: Real Time Submission of Electronic Claims

Subject: Real Time Submission of Electronic Claims

Aiming to improve Providers’ revenue cycle as well as monitoring of

quality, cost of services provided within the Abu Dhabi healthcare
system and access, HAAD would like to encourage real time processing
of electronic transactions.
Subject: Real Time Submission of Electronic Claims

Given the increased maturity of providers’ information system and

processes, from 1st June 2017, all healthcare providers are requested
to submit electronic claims no later than 24 hours after the end of
the encounter. In relation to that necessary amendments are being
made to the standard provider contract (SPC). Therefore all payers
are kindly requested to observe related changes and strictly follow
the above new rules for claims submission.
CHALLENGES THAT
CODERS FACE ON A
REGULAR BASIS
CHALLENGES THAT CODERS FACE
ON A REGULAR BASIS

1. Poor Documentation – A coder cannot assign

a code unless the provider has documented the
condition or procedure. The golden rule in coding
is,

“If it’s not documented, it wasn’t

done, and you can’t code it.”
 CHALLENGES THAT CODERS
FACE ON A REGULAR BASIS

2. Insufficient Documentation Errors: Claims are

determined to have insufficient documentation errors
when the medical documentation submitted is
inadequate to support payment for the services billed
 CHALLENGES THAT CODERS
FACE ON A REGULAR BASIS

Consequence of Insufficient Documentation

The document reviewer could not conclude:

1. Some of the billed services were actually provided.

2. Services were provided at the level billed.
3. Services were medically necessary.
 Type of diabetes mellitus not documented

 If the type of diabetes mellitus is not documented in the medical

record the default is E11.-, Type 2 diabetes mellitus.
 Coding of Pregnant state, incidental

This code is a secondary code only for use when the pregnancy is in no
way complicating the reason for visit. Otherwise, a code from the
obstetric chapter is required.

It is the provider’s responsibility to state that the condition being

treated is NOT affecting the pregnancy.

Approximate Synonyms

 Patient pregnant during encounter for other complaint

 Coding of Traumatic Fractures

 A fracture not indicated as open or closed should be coded to

closed.

 A fracture not indicated whether displaced or not displaced should

be coded to displaced.
Some documentation Discrepancies
Some documentation Discrepancies
PREPROCEDURE DIAGNOSIS: Change in bowel function.

POSTPROCEDURE DIAGNOSIS: Proctosigmoiditis.

PROCEDURE PERFORMED: Colonoscopy with biopsy.

ANESTHESIA: IV sedation.

POSTPROCEDURE CONDITION: Stable.

INDICATIONS: The patient is a 33-year-old with a recent change in bowel function and
hematochezia. He is here for colonoscopy. He understands the risks and wishes to
proceed.

PROCEDURE: The patient was brought to the endoscopy suite where he was placed in left
lateral Sims position, underwent IV sedation. Digital rectal examination was performed,
which showed no masses, and a boggy prostate. The colonoscope was placed in the
rectum and advanced, under direct vision, to the cecum. In the rectum and sigmoid, there
were ulcerations, edema, mucosal abnormalities, and loss of vascular pattern consistent
with proctosigmoiditis. Multiple random biopsies were taken of the left and right colon to
see if this was in fact pan colitis.

RECOMMENDATIONS: Follow up with me in 2 weeks and we will begin Canasa

suppositories.
Upper GI Endoscopy Procedure Note
PROCEDURE: The patient was sedated with intravenous fentanyl 75 mcg and intravenous
Versed, 5 mg, both titrated over the first ten minutes of the procedure time to achieve
adequate sedation for the procedure. Cetacaine spray was applied to the hypopharynx for
local anesthesia. The upper endoscope was passed without difficulty, into the upper GI tract.
The anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus,
and small bowel were all carefully inspected. All structures were visually normal in
appearance. Biopsies of the distal duodenum, gastric antrum, and distal esophagus were
taken and sent for pathological evaluation. The endoscope and insufflated air were slowly
removed from the upper GI tract. A repeat look at the structures involved again showed no
visible abnormalities, except for the biopsy sites.

The patient tolerated the procedure with excellent comfort and stable vital signs. After a
recovery period in the Endoscopy Suite, the patient is discharged to continue recovering in
the family's care at home. The family knows to follow up with me today if there are concerns
about the patient's recovery
from the procedure. They will follow up with me later this week for biopsy and CLO test
results so that appropriate further diagnostic and therapeutic plans can be made.
 Current documentation Issues
 Do NOT copy/paste the chief complaint from previous visits.

 Usage of Diagnosis Remarks box for any rule-out

conditions/exclusions related to labs and other investigations.

 Pregnancy YES/NO Documentation.

 Pregnancy weeks – Gestational Weeks

 Documentation of chronic conditions in medical history.

 Supporting diagnosis for labs and its documentation in the report and
for the prescription medication.

 Type of Asthma – specific documentation (Intermittent, Mild,

Moderate Persistent, Persistent, Severe Persistent).
 Current documentation Issues
 Laterality and specific anatomic site of the condition.

 Conclusion report in detail for all the clinical procedures including

Dermatology.

 EGD Procedure notes.

 Usage of ER/GP module (Eg. Dressing, medication refill, referrals,

suture removal, followup checkups).

 Sepsis documentation.

 ECG (CPT 93000) interpretation report (don’t provide symptoms as

chest pain in the conclusion report).

 Scanned reports of all ECGs must be there in the system.

 If the patient had any test done outside, please document that as well
and if possible scan them in the system as well.
 Some documentation Discrepancies

 For ADNIC, Oman, and AXA insurance, plantar warts diagnosis is not
covered, hence provide appropriate diagnosis to cover the service
rendered.

 Chest pain, please specify the duration since when the pain is present.

 Diarrhea, please mention the frequency and type of diarrhea.

 OMAN Insurance, no symptoms as Primary Diagnosis.

 External Cause of Injury/trauma must be documented.

 Documentation for cause-and-relationship (Eg. Diabetic neuropathy,

hypertensive heart disease).