Coding

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HIM215FinalProjectGuidelines andRubricOverviewMedicalcoding isoneofthemain enginesdrivingthehealthcaresystem. Whilenotvisibletoall stakeholders,medical codersareessential. Withoutthem,thehealthcareindustrywouldbeunabletoefficientlyshareimportantinformation,which could resultin healthcareprovidersnotreceiving paymentfor their services.Morespecifically,a medical codertranslatestherecordsof patientvisitsintonumericand alphanumericcode. This coding processisessential to ensuring thataccuratebillsand claimsareestablished.In thisassignment,youwillbetaskedwith reviewing apatientrecord and applying theappropriatecoding tothedifferentsections. Whilecoding thepatient record,you willworkwith ICD-10,HCPCS II,and CPTclassification systemstoaccuratelycodediagnosesandprocedures. Alongwith thecoded patientrecord, youwill alsoprovidea rationalethatcommunicateshowyou arrived atyour decisionsfor particularcodes.Theprojectis divided intothree milestones,which will besubmitted atvariouspointsthroughoutthecoursetoscaffold learning and ensurequalityfinal submissions.Themilestonesfor thiscoursewillhelpyou practicetheelementsof thefinal project.Thesemilestoneswill besubmitted in ModulesThree,Four, and Five.Thefinal productwill besubmitted in Module Seven.In thisassignment,youwilldemonstrateyourmasteryofthefollowing courseoutcomes:•Identifythemain termswithin a patienthealth recordfor determining valid coding•Differentiatebetween differentcoding classification systemsfor ensuringeffectiverecording ofpatienthealth information•Explain theprocessand resultsofvalidating correctcodethrough theeffectiveuseofelectronichealthcareresources•Applyappropriatehealthcareguidelinesinmaking determinationsof coding assignmentsPromptFor thisproject,youwill reviewa patientrecordand applytheappropriatediagnosis and procedurecoding. Youwill alsoprovidea rationalethatcommunicateshowyouarrived atyour decision for a particular code.Note: Thepatientrecord you will useforthefinal projectisnotthesamerecordyouwill useforthemilestones. Specifically,thefollowingcriticalelements mustbeaddressed:I.ICD-10: Inthis section,youwill reviewthepatientmedical record and applytheappropriateICD-10coding tothediagnosis.Youwill alsobeaskedto provideyour rationaleforhowyouarrived ataparticular code.A. Reviewthechartnotesand determineadiagnosis.Explain howyouarrived atyour determination. B. Determinetheprimaryand secondarydiagnosis.Describewhatledyoutothis determination.
C. Identifythemainterm(s)for each diagnosisand providea rationaletosupportyour response.D. Usean encoderand searchforthemain termofthediagnosis. Describetheresultsofthesearch and theprocessappliedtoeffectivelyusethe encoder.Note:YouwilluseSelectCoderasyourencoder forthis task.E. Describehowyou narrowed downyour diagnosisselectionbased on descriptionsand adjectiveswhileusing theencoder.Providethenarrowed-down listtosupportyour response.F.Assignthe diagnosiscode totherecord andexplain whythis codeis themostappropriateforthis diagnosis.II.HCPCSII: Inthissection,you will reviewthepatientmedical record and applytheappropriateHCPCSII coding totheprocedure(s). Youwill alsobeasked toprovideyour rationalefor howyouarrived ataparticular code.A. Reviewthechartnotesand determinetheHCPCSIIprocedure. Explain howyouarrived atyour determination. B. Identifythemainterm(s)for each HCPCS II procedureand providea rationaletosupportyour identification.C. Usean encoderand searchforthemain termoftheHCPCS II procedure.Describetheresultsofthesearchand theprocessapplied toeffectively usetheencoder. Note:Youwill useSelectCoder asyour encoder for thistask.D. Describehowyou narrowed downyour HCPCS II procedure selection basedon descriptionsand adjectiveswhileusing theencoder.Providethe narrowed-down listtosupportyour response.E. Assign theHCPCS II procedure codetotherecord andexplain whythiscodeisthemostappropriatefor thisprocedure.III.CPT:In thissection,you will reviewthepatientmedical record and apply theappropriateCPTcoding totheprocedure(s). Youwill alsobeasked to provideyour rationaleforhowyouarrived ataparticular code.A. Reviewthechartnotesand determineaCPTprocedure. Explain howyou arrivedatyour determination. B. Identifythemainterm(s)for each CPTprocedureand providea rationaletosupportyour identification.C. Usean encoderand searchforthemain termoftheCPTprocedure.Describetheresultsofthesearch and theprocessappliedtoeffectivelyuse theencoder.D. Describehowyou narrowed downyourCPTprocedure selection basedon descriptionsand adjectiveswhileusing theencoder.Providethe narrowed-down listtosupportyour response.E. Assign theCPTprocedurecodetotherecord andexplain whythiscodeisthemostappropriatefor thisprocedure.

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