Tag Archives: medical records

Medical Transcription Week – May 15-21

MTWEEK2016PICThough it is the end of the week, I have not forgotten that this week is National Medical Transcription Week.  I’ve been busy…. well transcribing!  There are not many  MTs around as compared to years’ past, but I still want to say a big thank you to those of us who are still here transcribing for doctors, nurse practitioners, fellows, etc., who have withstood  the many changes that have taken place over the years with being a medical transcriptionist, and lastly, being loyal to what you know and love.  A patient’s medical record would not be in existence if not for the medical transcriptionist.  As the trend of medical transcription has drastically changed over the years and evolved into more of the voice recognition editing, there are quite a few who are still doing the standard transcribing, which MTs consider ‘straight typing’ or ‘straight transcription.’

Speaking of voice recognition, here are a few ‘bloopers’ of voice recognition that we as medical transcriptionists/medical language specialists have to correct:

  • Voice recognition picks up:  ” Family accompanies her to the adult.”  This should be: “Family accompanies her to the toilet.”
  • Voice recognition: “Mother took patient to another antibiotic physician.” Should be: ” Mother took patient to a naturopathic physician.”
  • Voice recognition: ” Vaginal exam also somewhat superman genitalia. Should be: “Vaginal exam reveals normal external genitalia.”

Though these ‘bloopers’ are our transcription funnies, there really is nothing to laugh about when it comes to these types of errors in a patient’s medical record.  That is why it is extremely important to have a skilled, knowledgeable medical transcriptionist who knows and is thorough in medical terminology, anatomy and physiology and pharmacology to do this job, not just a typist!  There is finally controversy and action being taken now regarding voice recognition versus traditional transcription and these types of errors occurring in the patients medical record. As voice recognition was designed to ‘pick up’ the doctors voice as he is dictating, it is actually doing more harm than good – something now even a very keen patient recognizes in his or her medical record, leaving the patient to take legal action for these gross negligent errors, all in the name of trying to ‘produce’ a certain amount of work rather than being quality conscious. A well-trained medical transcriptionist who remembers traditional transcription realizes that even to this day, it would be simpler to transcribe the entire report than try and ‘fix’ the edited/voice recognition version.  That is a completely different subject that I will not acknowledge right now……

Again, Happy Medical Transcription Week everyone. Thank you for your hard work, your unique listening ear, your fast fingers on the keyboard, the long hours you put in, and your dedication to helping keep safeguard of each and every patients medical record!

ICD-10 coming in October – how it will affect patients

What is ICD-10? ICD-10 (International Statistical Classification of Diseases) and relatedquick-icd-10-1-l-280x280 problems is the 10th edition of the medical classification of medical coding. These are developed by the World Health Organization (WHO) and will officially replace ICD9-CM coding system here in the United states October 1, 2015. ICD-10 will include up to 7 digit codes along with letters.  ICD-9-CM has been around since 1979 and ICD-10 will bring a refreshing, much needed ‘upgrade’ to the health care system of the future. (Other countries have already been using ICD-10 for a while now and are beginning to work on ICD-11).

We first must understand that ICD-9-CM (International Classification of Diseases, Clinical Modification) is the assigning of codes to every human being given a diagnosis, whether inpatient, outpatient, surgical or procedural, hospital or doctor’s office – any HIPAA compliant entity.  ICD-10 is a significant expansion of medical codes (155,000) than the 17,000 that ICD-9-CM had.

What does ICD-10 mean to me? If you or I went to the doctor and was given a diagnosis of allergic rhinitis for example, the code would be 477 (ICD-9 code).  This means that every medical professional across the United states and other parts of the world understand the same diagnosis code for allergic rhinitis of 477.  There are several lists for this code, in which ICD-10 has more specificity of what type of allergic rhinitis there is (J30.1 is the ICD-10 code) and more specific codes for the different types of allergic rhinitis. As more and more electronic medical records are put into practice in this country, the more these codes affect patient care. The true change that we as patients will really notice will come in the reimbursements and billing of our insurance, Medicare and Medicaid and all entities who are HIPAA compliant.  Insurance payers will need to watch out for double billing and double payments as there are very stiff penalties in place for this, including fraud.  So the next time you go to your physician’s office and you get that receipt, or once admitted to the hospital and upon discharge and your billing statement comes to you, be sure to go over it with a fine tooth comb – making sure you have not been double billed for services rendered.  That’s why it is also important to TRY and remain as healthy as possible, to diminish so much coding because there is a code for everything now!