Part -1:
Overview: In the final project for this course, 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.
Prompt: In this milestone, you will practice coding CPT and E/M, which will prepare you for the final project. You will identify the proper procedures and main terms for each procedure, and code CPT and E/M. Use this patient record. In Milestone One, you reviewed an outpatient record, but for Milestones Two and Three, you will work with an inpatient record to prepare you for the final project. This is a good time to iron out any specific issues you are having and to contact your instructor with questions. There is a great deal of information in the patient record, so to help you focus on the CPT and E/M coding, the relevant sections of the record are highlighted. The following steps will also help you review the record:
- Begin by reviewing the entire record.
- Evaluate the face sheet for any diagnosis and/or procedures.
- Proceed to the discharge summary to evaluate whether anything further is discussed or explained as far as the patient's treatment is concerned.
- Proceed to the history and physical section. It should be reflective of the discharge summary; however, pay close attention to anything that you did not see in the discharge summary.
- The progress note is a step-by-step, day-by-day breakdown of the history/physical section. Much of it will duplicate what you have already reviewed; however, it is important to review it to ensure that nothing else should be coded.
- The reports at the end validate the procedures that were completed. If you find an emergency report, you should review it for consistency with the history/physical section and the discharge summary.
Note: The patient record you will use in this milestone is not the same record you will use for the final project. Specifically, the following critical elements must be addressed:
BI.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.
Part -2:
Overview: Journal activities in this course are private between you and the instructor. In this journal, you will review the case study for the final project and begin thinking about how you will complete the project.
Prompt: Review the patient case study for the final project and then address the following:
- Discuss how you will determine which codes are ICD, CPT, or HCPCS II.
- Identify some of the main terms you see in the patient record.
- Identify any terms you understand or are struggling to understand. Explain. This is a great opportunity to ask questions or reflect on parts of the process you are struggling with.
Attachment:- patient_record.rar