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