Identify the main terms within a patient health record

Assignment Help Other Subject
Reference no: EM131880048

Final Project

Overview

Medical coding is one of the main engines driving the healthcare system. While not visible to all stakeholders, medical coders are essential. Without them, the healthcare industry would be unable to efficiently share important information, which could result in healthcare providers not receiving payment for their services. More specifically, a medical coder translates the records of patient visits into numeric and alphanumeric code. This coding process is essential to ensuring that accurate bills and claims are established.

In this assignment, you will be tasked with reviewing a patient record and applying the appropriate coding to the different sections. While coding the patient record, you will work with ICD-10, HCPCS II, and CPT classification systems to accurately code diagnoses and procedures. Along with the coded patient record, you will also provide a rationale that communicates how you arrived at your decisions for particular codes.

The project is divided into three milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. The milestones for this course will help you practice the elements of the final project. These milestones will be submitted in Modules Three, Four, and Five. The final product will be submitted in Module Seven.

In this assignment, you will demonstrate your mastery of the following course outcomes:

- Identify the main terms within a patient health record for determining valid coding
- Differentiate between different coding classification systems for ensuring effective recording of patient health information
- Explain the process and results of validating correct code through the effective use of electronic healthcare resources
- Apply appropriate healthcare guidelines in making determinations of coding assignments

Prompt
For this project, you will review a patient record and apply the appropriate diagnosis and procedure coding. You will also provide a rationale that communicates how you arrived at your decision for a particular code.

Note: The patient record you will use for the final project is not the same record you will use for the milestones. Specifically, the following critical elements must be addressed:

I. ICD-10: In this section, you will review the patient medical record and apply the appropriate ICD-10 coding to the diagnosis. You will also be asked to provide your rationale for how you arrived at a particular code.

A. Review the chart notes and determine a diagnosis. Explain how you arrived at your determination.

B. Determine the primary and secondary diagnosis. Describe what led you to this determination.

C. Identify the main term(s) for each diagnosis and provide a rationale to support your response.

D. Use an encoder and search for the main term of the diagnosis. Describe the results of the search and the process applied to effectively use the encoder. Note: You will use SelectCoder as your encoder for this task.

E. Describe how you narrowed down your diagnosis selection based on descriptions and adjectives while using the encoder. Provide the narrowed- down list to support your response.

F. Assign the diagnosis code to the record and explain why this code is the most appropriate for this diagnosis.

II. HCPCS II: In this section, you will review the patient medical record and apply the appropriate HCPCS II coding to the procedure(s). You will also be asked to provide your rationale for how you arrived at a particular code.

A. Review the chart notes and determine the HCPCS II procedure. Explain how you arrived at your determination.

B. Identify the main term(s) for each HCPCS II procedure and provide a rationale to support your identification.

C. Use an encoder and search for the main term of the HCPCS II procedure. Describe the results of the search and the process applied to effectively use the encoder. Note: You will use SelectCoder as your encoder for this task.

D. Describe how you narrowed down your HCPCS II procedure selection based on descriptions and adjectives while using the encoder. Provide the narrowed-down list to support your response.

E. Assign the HCPCS II procedure code to the record and explain why this code is the most appropriate for this procedure.

III. CPT: In this section, you will review the patient medical record and apply the appropriate CPT coding to the procedure(s). You will also be asked to provide your rationale for how you arrived at a particular code.

A. Review the chart notes and determine a CPT procedure. Explain how you arrived at your determination.

B. Identify the main term(s) for each CPT procedure and provide a rationale to support your identification.

C. Use an encoder and search for the main term of the CPT procedure. Describe the results of the search and the process applied to effectively use the encoder.

D. Describe how you narrowed down your CPT procedure selection based on descriptions and adjectives while using the encoder. Provide the narrowed-down list to support your response.

E. Assign the CPT procedure code to the record and explain why this code is the most appropriate for this procedure.

Milestone One: ICD-10 Coding

Milestones

In Module Three, you will practice coding ICD-10. You will identify the ICD-10 diagnosis, determine which diagnosis is primary and which is secondary, identify the main terms, and use SelectCoder to code in ICD-10. This is a good time to iron out any specific issues you are having and contact the instructor with questions. This milestone will be graded with the Milestone One Rubric.

Milestone Two: HCPCS II Coding
In Module Four, you will practice coding HCPCS II. You will identify the proper procedures and main terms for each procedure, and code HCPCS II. This is a good time to iron out any specific issues you are having and contact the instructor with questions. This milestone will be graded with the Milestone Two Rubric.

Milestone Three: CPT and E/M Coding
In Module Five, you will practice coding CPT and E/M. You will identify the proper procedures and main terms for each procedure, and code CPT and E/M. This is a good time to iron out any specific issues you are having and contact the instructor with questions. This milestone will be graded with the Milestone Three Rubric.

Attachment:- Patient record.rar

Verified Expert

The task is about medical coding in 3 categories specifically ICD-10; HCPCS-II, and CPT. The task has been prepared on MS Word. APA format of referencing has been followed.

Reference no: EM131880048

Questions Cloud

Write a complaint letter to ms arletta sandusky : Premier is a catalog company that provides imprinted promotional products for companies.
Why outcomes data like infection rates cannot be evaluated : Explain why outcomes data like infection rates cannot be evaluated only at face value. Support you explanation with examples of other data/information.
Analyze any of the themes that have emerged : Analyze any of the themes that have emerged from the texts we have discussed thus far; these includeEva's Man.
How would you modify the documenting of issues : How would you modify the documenting of issues? What would you do differently to communicate the project's issues?
Identify the main terms within a patient health record : HIM 215 Identify the main terms within a patient health record for determining valid coding - Differentiate between different coding classification systems
Disciss about the services sleep and rest routines : Why it is particularly important to talk to families for whom English is a second language about the service's sleep and rest routines.
Explain why charles lindberg was very happy : Explain why Charles Lindberg was very happy with the lateral stability of the Spirit of St. Louis. Was it negative, neutral or positive?
Explain the kind of museum you visited : Provide an information page in which you explain the kind of museum you visited and provide a brief overview of its holdings-no more than one page.
How nutritional epidemiology can impact population health : Choose one population from the article write a 3-5 page essay detailing how nutritional epidemiology can impact the population health?

Reviews

len1880048

2/26/2018 7:24:14 AM

Articulation of Response Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-to-read format Submission has no major errors related to citations, grammar, spelling, syntax, or organization Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas 4.96 Total 100%

len1880048

2/26/2018 7:24:08 AM

CPT: Procedure Selection Meets “Proficient” criteria, and description offers keen insight into narrowing procedure options when using an encoder Describes how the CPT procedure selection was narrowed down based on descriptions and adjectives while using the encoder, and provides the narrowed-down list to support response Describes how the CPT procedure selection was narrowed down based on descriptions and adjectives while using the encoder, and provides the narrowed-down list, but description is cursory or inaccurate, or provided list does not support response Does not describe how CPT procedure selection was narrowed down 3.96 CPT: Procedure Code Meets “Proficient” criteria, and explanation demonstrates a complex grasp on assigning codes to records Assigns the CPT procedure code to the record, explaining why the code is most appropriate for the procedure Assigns the CPT procedure code to the record, explaining why the code is most appropriate for the procedure, but explanation is cursory or illogical Does not assign the CPT procedure code to the record 7.92

len1880048

2/26/2018 7:24:01 AM

CPT: Main Term(s) Meets “Proficient” criteria, and rationale demonstrates a complex grasp on identifying main terms Identifies the main term(s) for each CPT procedure and provides rationale to support response Identifies the main term(s) for each CPT procedure and provides rationale to support response, but rationale is cursory or illogical Does not identify the main term(s) for each CPT procedure 7.92 CPT: Encoder Meets “Proficient” criteria, and description demonstrates a sophisticated awareness of how to use an encoder effectively Describes the results of the search and the process applied to effectively use the encoder Describes the results of the search and the process applied to effectively use the encoder, but description is cursory or lacks detail, or some results are inaccurate Does not describe the results of the search 3.96

len1880048

2/26/2018 7:23:56 AM

HCPCS II: Procedure Code Meets “Proficient” criteria, and explanation demonstrates a complex grasp on assigning codes to records Assigns the HCPCS II procedure code to the record, explaining why the code is most appropriate for the procedure Assigns the HCPCS II procedure code to the record, explaining why the code is most appropriate for the procedure, but explanation is cursory or illogical Does not assign the HCPCS II procedure code to the record 7.92 CPT: CPT Procedure Meets “Proficient” criteria, and explanation demonstrates keen insight into making CPT procedure determinations Determines a CPT procedure, explaining how the CPT procedure was determined Determines a CPT procedure and explains how the CPT procedure was determined, but explanation is cursory or lacks detail Does not determine a CPT procedure 5.94

len1880048

2/26/2018 7:23:46 AM

HCPCS II: Encoder Meets “Proficient” criteria, and description demonstrates a sophisticated awareness of how to use an encoder effectively Describes the results of the search and the process applied to effectively use the encoder Describes the results of the search and the process applied to effectively use the encoder, but description is cursory or lacks detail, or some results are inaccurate Does not describe the results of the search 3.96 HCPCS II: Procedure Selection Meets “Proficient” criteria, and description offers keen insight into narrowing procedure options when using an encoder Describes how the HCPCS II procedure selection was narrowed down based on descriptions and adjectives while using the encoder, and provides the narrowed-down list to support response Describes how the HCPCS II procedure selection was narrowed down based on descriptions and adjectives while using the encoder, and provides the narrowed-down list, but description is cursory or inaccurate, or provided list does not support response Does not describe how HCPCS II procedure selection was narrowed down 3.96

len1880048

2/26/2018 7:23:39 AM

HCPCS II: HCPCS II Procedure Meets “Proficient” criteria, and explanation demonstrates keen insight into making HCPCS II procedure determinations Determines a HCPCS II procedure, explaining how the HCPCS II procedure was determined Determines a HCPCS II procedure and explains how the HCPCS II procedure was determined, but explanation is cursory or lacks detail Does not determine a HCPCS II procedure 5.94 HCPCS II: Main Term(s) Meets “Proficient” criteria, and rationale demonstrates a complex grasp on identifying main terms Identifies the main term(s) for each HCPCS II procedure and provides rationale to support response Identifies the main term(s) for each HCPCS II procedure and provides rationale to support response, but rationale is cursory or illogical Does not identify the main term(s) for each HCPCS II procedure 7.92

len1880048

2/26/2018 7:23:34 AM

ICD-10: Diagnosis Selection Meets “Proficient” criteria, and description offers keen insight into narrowing diagnosis options when using an encoder Describes how the diagnosis selection was narrowed down based on descriptions and adjectives while using the encoder, and provides the narrowed-down list to support response Describes how the diagnosis selection was narrowed down based on descriptions and adjectives while using the encoder, and provides the narrowed-down list, but description is cursory or inaccurate, or provided list does not support response Does not describe how the diagnosis selection was narrowed down 3.96 ICD-10: Assign the Diagnosis Code Meets “Proficient” criteria, and explanation demonstrates a complex grasp on assigning codes to records Assigns the diagnosis code to the record, explaining why the code is most appropriate for the diagnosis Assigns the diagnosis code to the record, explaining why the code is most appropriate for the diagnosis, but explanation is cursory or illogical Does not assign the diagnosis code to the record 7.92

len1880048

2/26/2018 7:23:28 AM

ICD-10: Main Term(s) Meets “Proficient” criteria, and rationale demonstrates a complex grasp on identifying main terms Identifies the main term(s) for each diagnosis and provides rationale to support response Identifies the main term(s) for each diagnosis and provides rationale to support response, but rationale is cursory or illogical Does not identify the main term(s) for each diagnosis 7.92 ICD-10: Encoder Meets “Proficient” criteria, and description demonstrates a sophisticated awareness of how to use an encoder effectively Describes the results of the search and the process applied to effectively use the encoder Describes the results of the search and the process applied to effectively use the encoder, but description is cursory or lacks detail, or some results are inaccurate Does not describe the results of the search 3.96

len1880048

2/26/2018 7:23:22 AM

Final Project Rubric Guidelines for Submission: Your coded patient record with rationale should be a 1- to 2-page Microsoft Word document, double spaced, with 12-pt. Times New Roman Font, one-inch margins, and APA formatting. Critical Elements Exemplary (100%) Proficient (85%) Needs Improvement (55%) Not Evident (0%) Value ICD-10: Diagnosis Meets “Proficient” criteria, and explanation demonstrates keen insight into making diagnosis determinations Determines a diagnosis, explaining how the diagnosis was determined Determines a diagnosis and explains how the diagnosis was determined, but explanation is cursory or lacks detail Does not determine a diagnosis 5.94 ICD-10: Primary and Secondary Meets “Proficient” criteria, and description demonstrates keen insight into classifying diagnoses as primary or secondary Determines the primary and secondary diagnosis and describes what led to this determination Determines the primary and secondary diagnosis and describes what led to this determination, but description is cursory or lacks detail Does not determine the primary and secondary diagnosis 5.94

len1880048

2/26/2018 7:23:15 AM

Final Submission: Coded Patient Record with Rationale In Module Seven, you will submit your final project. It should be a complete, polished artifact containing all of the critical elements of the final product. It should reflect the incorporation of feedback gained throughout the course. This submission will be graded with the Final Project Rubric. Deliverables Milestone Deliverable Module Due Grading One ICD-10 Coding Three Graded separately; Milestone One Rubric Two HCPCS II Coding Four Graded separately; Milestone Two Rubric Three CPT and E/M Coding Five Graded separately; Milestone Three Rubric Final Submission: Coded Patient Record with Rationale Seven Graded separately; Final Project Rubric

Write a Review

Other Subject Questions & Answers

  Cross-cultural opportunities and conflicts in canada

Short Paper on Cross-cultural Opportunities and Conflicts in Canada.

  Sociology theory questions

Sociology are very fundamental in nature. Role strain and role constraint speak about the duties and responsibilities of the roles of people in society or in a group. A short theory about Darwin and Moths is also answered.

  A book review on unfaithful angels

This review will help the reader understand the social work profession through different concepts giving the glimpse of why the social work profession might have drifted away from its original purpose of serving the poor.

  Disorder paper: schizophrenia

Schizophrenia does not really have just one single cause. It is a possibility that this disorder could be inherited but not all doctors are sure.

  Individual assignment: two models handout and rubric

Individual Assignment : Two Models Handout and Rubric,    This paper will allow you to understand and evaluate two vastly different organizational models and to effectively communicate their differences.

  Developing strategic intent for toyota

The following report includes the description about the organization, its strategies, industry analysis in which it operates and its position in the industry.

  Gasoline powered passenger vehicles

In this study, we examine how gasoline price volatility and income of the consumers impacts consumer's demand for gasoline.

  An aspect of poverty in canada

Economics thesis undergrad 4th year paper to write. it should be about 22 pages in length, literature review, economic analysis and then data or cost benefit analysis.

  Ngn customer satisfaction qos indicator for 3g services

The paper aims to highlight the global trends in countries and regions where 3G has already been introduced and propose an implementation plan to the telecom operators of developing countries.

  Prepare a power point presentation

Prepare the power point presentation for the case: Santa Fe Independent School District

  Information literacy is important in this environment

Information literacy is critically important in this contemporary environment

  Associative property of multiplication

Write a definition for associative property of multiplication.

Free Assignment Quote

Assured A++ Grade

Get guaranteed satisfaction & time on delivery in every assignment order you paid with us! We ensure premium quality solution document along with free turntin report!

All rights reserved! Copyrights ©2019-2020 ExpertsMind IT Educational Pvt Ltd