Medical coding systems

Unit outcomes addressed in this Assignment:

 

· Apply diagnostic and procedure codes according to current guidelines using common classification systems, taxonomies, nomenclatures and terminologies

· Identify the documentation needs that relate to quality coding practices

· Discuss the role of coding with the key features of an electronic health record (EHR) system and clinical document standards.

· Discuss the importance and relevance of Computer-Assisted Coding along with coding problems that may arise.

Course outcome(s) practiced in this unit:

HI253-5:  Appraise a health record for deficiencies needed for quality coding (Bloom’s Level 4)

 

AHIMA’s Professional Coding Approved Program (PCAP) Mapping:

Domain I. Data Content, Structure & Standards (Information Governance)

· Subdomain I.A Classification Systems

· 1. Apply diagnosis/procedure codes according to current guidelines (Bloom’s Level 3)

· Classification Systems

· ICD (ICD-9-CM, ICD-10, ICD-10-CM/PCS)

· Taxonomies

· Clinical Care Classification (CCC)

· Nomenclatures

· CPT, DSM, RxNorm

· Terminologies

· LOINC, SNOMED CT

 

 

Instructions:

Part 1: Coding Scenario Worksheet (coding practice): Complete the coding scenarios worksheet indicated in Part 1 below by indicating the appropriate codes.

 

Part 2: Nuance Quantim Physician Query Activity: Please access the AHIMA’s Virtual Laboratories (VLabs) at http://academy.ahima.org/ website. Within the Virtual Lab (My Learning), go to the Virtual Lab applications and open the Nuance Quantim Encoder application and complete the Nuance Quantim #6 Activity on Physician Query activity with a passing score of 100% and appropriately identify the documentation needs that relate to quality coding practices. Answer the provided questions and submit a screen shot of your completed Physician Query activity in the Part 2 section of the Assignment Worksheet.

Part 3: Electronic Health Record and Coding Systems:

 

A. VistA Simulation: Please access the AHIMA’s Virtual Laboratories (VLabs) at http://academy.ahima.org/ and follow the instructions under Part 3. Once completed, take a screen shot of the completion page and attach to the appropriate Part 3 section of the Assignment Worksheet. Remember to review the VLab instructional sheet in Doc Sharing if you trouble navigating.

B. EHR and Coding Resources Comparison Table: Answer the question indicated and support your answer by providing a table to include where the resource would be located and how best to access.

Part 4: Computer-Assisted Coding: Refer to the information from your Unit 10 Discussion Board and provide your answers/discussion in the Part 4 section of the Assignment Worksheet.

 

 

Requirements:

· Your assignment worksheet may contain citations and references, and if used, should utilize APA style, with no more than 10% quoting. Please use paraphrasing, in-text citation, and referencing.

· Correct spelling and grammar should be utilized throughout and if required, the answers provided in complete sentences.

· The word count should reflect the following:

· Part 1 = Short answer 1-6 words; or applicable code.

· Part 2 = Short answer 1-6 words and VLabs screenshot.

· Part 3 = VLab screenshot; short answer 1-6 words and then 75-100 words for the entire table.

· Part 4 = 75-100 words

· Total = about 225-300 words with VLabs screenshot and completed coding worksheet.

 

 

ASSIGNMENT WORKSHEET

 

Part 1: Coding Scenarios Worksheet

 

Provide the correct code or short answer for the following questions and case scenarios :

 

1. A patient has a bundle of his recording and intra-atrial pacing done by Dr. Henry on 07/01/YY.  When using CPT to code these procedures, the coder should: code each procedure separately

2. Mary Joseph is a patient at a local hospital. She underwent surgery and had severe postoperative complications that included respiratory arrest and acute blood loss. She received critical care services for 85 minutes. CPT codes 99291 and 99292 are reported. Code 99292 is considered a(n) Neonatal intensive care______________________code

3. Wyatt presents to Dr. Franks’ office complaining of swollen neck glands. Dr. Frank does not find any other physical findings but orders laboratory tests. His impression is localized cervical lymphadenopathy. a. What is the main term utilized to code this case?   b. Assign the ICD-10-CM code:

4. Kelly presents with urinary frequency and nocturia. The doctor does not detect any abnormal findings but orders an IVP. a. What are the patient’s signs and symptoms? b. Assign the ICD-10-CM code:

5. Mary Jane had her tonsils taken out 2 days ago. She now presents with postoperative hemorrhage status post tonsillectomy. She requires control of her bleeding and was given Demerol 95 mg IM for pain.   What is the HCPCS code for Demerol? J2175

6. Joseph is a chemotherapy patient suffering from anemia secondary to treatment. He presents to his oncologist’s office for his routine B12 injection for vitamin B12 deficiency anemia due to the chemotherapy. Sytobex 1000 mg IM was provided.   What is the HCPCS code for the Sytobex? J3420

7. Anesthesia services are organized by what process in the CPT Coding Book? Body site

8. A patient on vacation out of state fractures her leg and sees a doctor who sets the fracture.   The out-of-state physician will report which modifier to the code?

9. Identify the main term from this statement used for CPT coding: “Sinus endoscopy with concha bullosa resection: concha bullosa

10. How many possible values are there for each character in an ICD-10-PCS code?

11. Which of the following is an invalid code? “06H033T” or “06H14DZ”? Explain your answer:

12. Which of the following codes is an invalid code “3E0F37Z” or “3E0F03D”?   Explain your answer:

 

 

 

 

 

Part 2: Nuance Quantim Physician Query Activity and Documentation Practices

 

A. Provide brief answers to the following:

 

1. Provide the definition of principal diagnosis:

2. List the criteria that must be met in order to report a diagnosis or condition as secondary:

3. Explain the circumstances in which the present on admission (POA) indicator would be listed as “N”:

4. Which portion of the medical record contains documentation of the postoperative diagnosis?

5. Terms such as “hospital course” and “final diagnosis” are located in which inpatient report in the medical record?

6. When coding an inpatient medical record, the coder should review which document(s) to determine the reason a test was ordered?

7. The patient’s reason for the visit is often referred to as the chief complaint. What is the other term used to describe the chief complaint?

 

 

 

 

B. Nuance Quantim Physician Query #6 Activity: Submit screen shot of the completion page and attach here:

 

 

Part 3: Electronic Health Records and Coding Systems

 

A. VistA Simulation: Please access the AHIMA’s Virtual Laboratories (VLabs) at http://academy.ahima.org/ . Click on My Learning; Click on VLab Academy; Scroll to VistA; Click on the VistA Simulations. This is a PDF with links to the software simulations.

Click on “Coding an Office Visit”. Complete the simulation and take a screen shot of the completion page and attach it here:

B. EHR and Coding Resources Comparison Table: Answer the question indicated and support your answer by providing a table to include where the resource would be located and how best to access. Your information can be based on the three systems you have reviewed in Unit 9 and Unit 10 (Nuance Quantim, 3M Encloder, VistA) or other systems you have worked with or reviewed:

QUESTION: You are the coding supervisor at a major acute care hospital. What resources would you recommend to ensure that the most current ICD-10-CM/PCS codes are in use in your healthcare facility? Remember to address issues such as coding resources and computer systems.

 

Create a table outlining the features of health information systems and their advantages in coding. Support your information with examples. See example table below:

 

System Name	Attribute (Name)

 

 

Part 4: Computer-Assisted Coding

 

Refer to the information from your Unit 10 Discussion Board and provide your answers/discussion here:

 

Can computer assisted coding (CAC) be helpful to outpatient coders? CAC is a supporting technology that has reached an exciting stage of development. It holds a great deal of promise for assisting in further automation of the coding process. Although the technology holds great promise, it also faces a huge challenge because of the complexity and variability of human speech. However, promising new CAC products are beginning to emerge in certain medical arenas, such as emergency medicine and radiology.

Do you believe that systems such as the CAC system will reduce the need for coders? Why or why not? What problems might result from CAC?