Reference no: EM133763371
Coding Specialist Program
Instructions for Journaling
The journal entries should specifically and in detail, reflect how you decided what to code based on the documentation for the specific case. That is, what facts did you gather from the documentation, what coding conventions, rules and coding standard directive statements were applied; what research and resources helped guide your coding decisions? What challenges and dilemmas were encountered and how were they resolved?
Track your journal entries in a separate Word document. Journal templates are available in each module under the header Journal Activity. You will then upload this document to the Journal Submission area of that module so that it is available to your faculty coach for grading.
Record the specific details that justify or explain
ICD-10-CA code assignment, including:
The classification search query used to find the ICD-10-CA code, e.g., alphabetical index.
The alphabetical index look-up or the lead term and secondary term(s) used to search the classification for the ICD-10-CA code, e.g., lead term: infarction; secondary term: myocardial.
The excerpt from the clinical documentation and your interpretation of that documentation that supports assignment of the diagnosis code, e.g., the final diagnosis documented on discharge summary is STEMI acute anterior myocardial infarction.
The steps taken to reconcile ambiguous or conflicting documentation.
The specific coding convention, rule or instructional note that justifies code assignment and where it is found in the classification, e.g., per the code separately note at E11.52 Type 2 diabetes mellitus with certain circulatory complications, "code separately any of the following associated conditions: cerebrovascular diseases (I60-I69); or E11.23† Type 2 diabetes mellitus with established or advanced kidney disease (N08.3-*) and N08.35* Glomerular disorders in diabetes mellitus, chronic kidney disease, stage 5) per the dagger and asterisk convention.
The specific directive statement that supports code assignment, e.g., the Canadian Coding Standards for ICD-10-CA and CCI, General Coding Standards for ICD-10-CA, "Use Additional Code / Code Separately Instructions," assign the additional code, mandatory,
when a "code separately" instruction is found in ICD-10-CA and the condition meets the criteria for significance; and,
"Dagger / Asterisk Convention" an asterisk code is assigned whenever indicated in ICD- 10-CA.
- The resources used to increase your understanding of what was documented, e.g., research, textbooks such as the anatomy and physiology textbook and the pathophysiology textbook, CIHI coding question service (cite specific coding question #).
Application of diagnosis typing, including:
The specific directive statement that supports application of diagnosis type (3) or diagnosis type (6) to an asterisk code, e.g., the Canadian Coding Standards for ICD-10-CA and CCI, General Coding Standards for ICD-10-CA, "Dagger / Asterisk Convention" and "Diagnosis Typing Definitions for DAD," that directs that diagnosis type (3) is applied to an asterisk code or when the asterisk code is recorded in the second position of the diagnosis field on the abstract and meets the criteria for the most responsible diagnosis, diagnosis type (6) is applied to the asterisk code.
The specific directive statement that supports application of diagnosis type (M), (1) or (2) to an ICD-10-CA code, e.g., the Canadian Coding Standards for ICD-10-CA and CCI, General Coding Standards for ICD-10-CA, "Diagnosis Typing Definitions for DAD," D12.5 Benign neoplasm of sigmoid colon meets the criteria for significance (diagnosis type (1)) because the therapeutic intervention - 1.NM.87.BA Excision partial, large intestine, endoscopic per orifice approach, simple excisional technique - is mandatory for code
assignment per the coding standard "Selection of Interventions to Code for Acute Inpatient Care."
Application of data elements, including:
The specific directive statement that supports application of the diagnosis prefix and/or the diagnosis cluster, e.g., the Canadian Coding Standards for ICD-10-CA and CCI, General Coding Standards for ICD-10-CA, "Diagnosis Typing Definitions for DAD" - Prefix 5 and 6 and "Diagnosis Cluster," respectively.
Why an ICD-10-CA code or CCI code was not assigned, including:
The specific coding convention or rule and where it is found in the classification and/or the coding standards that supports that assignment of an ICD-10-CA code or a CCI code is optional (not mandatory). Therefore, it was not assigned.
CCI codes assigned, including:
The classification search query used to find the CCI code.
The generic intent and anatomy site used to search the classification for the CCI code.
The specific coding convention or rule and where it is found in the classification and/or the coding standards that further supports the direction, e.g., the Canadian Coding Standards for ICD-10-CA and CCI, General Coding Standards for CCI, "Selection of Interventions to Code for Acute Inpatient Care." CCI is service provider and service
setting neutral. 1.PZ.21.^^ Dialysis, urinary system NEC is on the "Additional Mandatory CCI Codes for Acute Inpatient Care" list. Therefore, it is mandatory to assign a code from rubric 1.PZ.21.^^ whenever dialysis is performed during an episode of care, regardless of
the intervention provider (e.g., patient himself, nurse, family member) and regardless of intervention location (e.g., dialysis clinic, inpatient unit bed).
Application of the CCI attribute, including:
The location attribute is mandatory to apply as denoted by the hot pink attribute box at rubric 1.NM.87.^^ Excision partial, large intestine. Therefore, per the pop-up note "U" - unqualified, not applicable or of unknown extent is applied to 1.NM.87.BA Excision partial, large intestine, endoscopic per orifice approach, simple excisional technique when the intervention performed is a simple excision of a lesion of the large intestine (e.g., polypectomy); or the Canadian Coding Standards for ICD-10-CA and CCI, General
Coding Standards for CCI, "Converted Interventions" and "Revised Interventions," which direct when applicable, status attribute "C" - converted and status attribute "R" - revised must be applied to the CCI code when an intervention begins as endoscopic and is changed to an open approach and when the current intervention is a complete or partial re-do of an intervention performed previously, respectively.
Case #1 - Acute Care Inpatient Episode of Care
Case Summary: The patient is admitted with angina. He is taken to the cardiac catheterization laboratory for a coronary angiogram (via femoral artery) and percutaneous coronary intervention of circumflex (Cx) artery with balloon dilator and insertion of sirolimus stent.
Final diagnosis: ST-segment elevation inferior wall myocardial infarction
Diagnoses
Module 1 - Case #2 - Acute Care Inpatient Episode of Care
Case Summary: The elderly patient with known hypertension is admitted unconscious, to a rural hospital. The admitting diagnosis is stroke. The family opted not to transfer her to the local hospital for diagnostic imaging. Comfort care only was provided. She passed peacefully 20 hours after admission. An autopsy was not performed.
Case #3 - Emgergency Department Visit
Case Summary: The patient presents to the emergency department with an injury to the right wrist following a fall. An X-ray is taken of the wrist, confirming a fracture of the distal radius. The fracture was reduced under fluoroscopy with post-reduction X-ray showing good alignment. A cast was applied and the patient was discharged.
Case #4 - Emergency Department Visit
Case Summary: The patient presents to the emergency department with chest pain. A 12-lead electrocardiogram (ECG) shows ST-segment elevations. An intravenous (IV) is started to keep veins open. Streptokinase is administered via IV and the patient is transferred to the provincial heart centre via ambulance.
Case #5 - Acute Care Inpatient Episode of Care
Case Summary: The patient is admitted with a glomerular filtration rate (GFR) of 21 for a thorough assessment to determine whether or not hemodialysis is required. The patient has type 1 diabetes mellitus.