Abstracting Documentation for Beginning Coders
In this Lab Activity, you will practice reading documentation in order to determine the following information:
Is the type of documentation for inpatient or outpatient services based on information in the documentation?
What are the diagnosis stated in the documentation?
What are the procedures stated in the documentation?
What coding systems will you use to code this documentation based on knowing the type of documentation, the diagnosis stated, and the procedure or procedures stated?
A reminder:
Outpatient includes all physician services, emergency room services, outpatient surgical procedures, observation services in a hospital, and consultations by a physician.
Inpatient is only hospital services provided when a patient stays longer than 24 hours in the hospital.
(For further details please refer to the information given in your course.)
Here is an example of how to do this Lab Activity:
If the documentation is outpatient and I have two diagnosis documented and one procedure documented, I will be using ICD 10 CM for the diagnosis coding and CPT for the outpatient procedure coding.
If the documentation is inpatient and I have two diagnosis and two procedures documented I will use ICD 10 CM for the diagnosis coding and ICD 10 PCS for the inpatient procedure coding.
Lab Activity Instructions:
In a Word document, create a simple table with 4 columns. Create the following headings in each column:
Type of Documentation
Diagnosis Documented
Procedures Documented
Coding Systems Needed
Use the five sets of documentation listed after these instructions and determine for each set of documentation the answer to each of the four questions above.
Read the documentation, determine the answers to put in each column, and place your answers in the appropriate column. ( Example: In column one indicate if you would code this as inpatient or outpatient. In column two indicate what diagnosis are given in the documentation.
In column three indicate what procedures are documented. In column four indicate which coding systems you would use to code.) Please number your answers.
DO NOT LOOK UP CODES. YOU ARE ONLY TO GIVE THE INFORMATION REQUIRED IN THE WORD TABLE HEADINGS YOU CREATED AND PER THE LAB ACTIVITY INSTRUCTIONS.
Complete your Word Document Table and submit it the drop box. If you do not know how to create a table, call PSC and they will help you.
Use the following five sets of documentation to complete the answers in your Word Table:
The physician conducted a routine office visit and removed a lesion from the patient's back by excision and repaired the excision with sutures. The lesion removed was a benign cyst.
A patient presented to the emergency room and tests revealed acute appendicitis with a rupture and abscess. The patient required surgery of an open appendectomy and required hospitalization and a two day hospital stay to prevent further infection.
A patient came into the emergency room and indications were suspect for a possible TIA or transient ischemic attack. He also was found to have hypertension and hyperlipidemia. No treatment was given as the TIA symptoms had resolved and the patient was released.
A patient was ordered by his physician after an office visit to be admitted to the hospital for acute recurring pancreatitis. While in the hospital he was also found to have gallstones and the surgeon performed a cholecystectomy to remove the gallbladder. He was hospitalized for three days.
A morbidly obese patient with a BMI of 48.2 requested gastric bypass surgery. This surgery was performed in an Ambulatory Surgical Center and he was released the same day after a successful surgery.