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Kaplan University, Davenport - HEALTH SCIENCE H1255
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Unit 9 Assignment Unit outcomes addressed in this Assignment: Assign diagnosis codes for the assigned chapters. Assign procedure codes relevant to the assigned chapters. Assign the CPT guidelines for the Evaluation and Management section services. Generate an action plan for clinical documentation improvement (CDI) Course outcomes addressed in this Assignment: HI255-3: Apply national guidelines and best practices to ensure quality coding. HI255-4: Evaluate clinical documentation for appropriate health information that supports quality coding practices. GEL-1.1: Demonstrate college-level communication through the composition of original materials in Standard American English. AHIMA’s Professional Coding Approved Program (PCAP) Mapping: Domain I. Data Content, Structure & Standards (Information Governance) Subdomain I.A Classification Systems 1. Apply diagnosis/procedure codes according to current guidelines (Bloom's Level 3) Classification Systems ICD (ICD-9-CM, ICD-10, ICD-10-CM/PCS) Taxonomies Clinical Care Classification (CCC) Nomenclatures CPT, DSM, RxNorm Terminologies LOINC, SNOMED CT PART ONE – CLINICAL DOCUMENTATION IMPROVEMENT Assignment Instructions (50 points): Review the information from your Unit 8 and Unit 9 Reading Lists pertaining to Clinical Documentation Improvement (CDI) and coding auditing for quality. Articles to review include, but are not limited to, the following: “Coding Audits Evolve with ICD-10: Industry Experts Define New Benchmarks and Best Practices” “Data Quality Audit: Understanding Coding Variations” “Using CDI programs to improve acute care clinical documentation in preparation for ICD-10-CM/PCS” In a 1–2 page paper (double spaced), address the following: What is Clinical Documentation Improvement (CDI) and its purpose? What is the impact of a good CDI program for both inpatient and outpatient facilities? What is the role of coding auditing and what does it entail? Identify an original and insightful “take away” from the articles reviewed and how it applies to the relationship between CDI, the principles of auditing, and quality coding practices. 3. You may utilize other outside sources such as the Kaplan On-Line Library and the AHIMA Body of Knowledge ( for the completion of your paper. All sources utilized include an APA formatted reference. Information on APA format for references can be found under the Academic Support Center, Writing Center. 4. Presented paper will be well-ordered, logical and unified in its presentation. 5. Submit the paper as part of the Unit 9 Assignment worksheet. PART TWO Instructions: Complete the following coding exercises by supplying the correct ICD-10-CM/ ICD-10-PCS, and/or CPT code(s) as appropriate: ICD-10-CM: Chapter on Mental, Behavioral and Neurodevelopmental Disorders: ICD-10-CM Code Description ICD-10-CM Code Opioid dependence with withdrawal F11.23 The patient was brought to the ER and then admitted because of acute alcohol inebriation. The discharge diagnosis is acute and chronic alcoholism, continuous. The patient also has a history of hypertension, for which he is currently taking medication for. The patient also suffers from a sleep disorder associated with opioid use. F10.211 I10. F11.982 Conduct disorder, oppositional defiant type F91.3 Bipolar disorder, current episode mixed, moderate F31.62 ICD-10-CM Chapter on Diseases of the Nervous System: ICD-10-CM Code Description ICD-10-CM Code Staphylococcal meningitis G00.3, B95.8 Patient was admitted when MRI revealed cerebral aneurysm. After admission, a cerebral angiogram was performed using fluoroscopy and low osmolar contrast. This revealed a nonruptured arteriosclerotic aneurysm of the left anterior cerebral artery. Later that day, the patient was taken to the operating room and underwent clipping of the anterior cerebral artery aneurysm via craniotomy. Assign both ICD-10-CM and ICD-10-PCS code(s):_ I67.1 B31R1ZZ 03VG0CZ Juvenile myoclonic epilepsy with intractable seizures G40.B11 Carpel tunnel syndrome and tarsal tunnel syndrome, both on left side. G56.02, G57.52 ICD-10-CM Chapter on Injury: ICD-10-CM Code Description ICD-10-CM Code Chronic pain from screw placed in right femur for repair of distal fracture, initial encounter. T84.84XA Patient was walking along the railroad tracks when a train hit him. He was taken to the Medical Center by ambulance. Surprisingly, there were no internal injuries, and the only injury sustained was significant trauma to both lower legs. Discharge diagnosis was bilateral traumatic amputation. A revision by further amputation of the traumatic amputations of the mid tibia and fibula to the nigh tibia and fibula was performed on both legs. Provide both the ICD-10-CM and ICD-10-PCS code(s): 0Y6GOZZ 0Y6F0ZZ 0SWUXJZ G89.21 Y93.01 Y14.90 Y92.85 Foreign body, cornea, right, initial encounter in emergency department (injury code only). T15.01XA ICD-10-CM Chapter on Poisoning and Certain Other Consequences of External Causes: ICD-10-CM Code Description ICD-10-CM Code Child is seen emergently for an accidental overdose of acetaminophen. He inadvertently ate several of theses when he found an open bottle at home: T39.1X1A The patient is a 2-year-old female who had a heart transplant in the past year and was admitted to the hospital and diagnosed with a viral pneumonia due to parvovirus, which is a complication of her heart transplant status Z94.9 J12.9 The patient is a 30-year-old male who works in a local zoo and was bitten by a venomous rattlesnake on his left arm while attempting to move the snake to a transportation container. A small open wound was treated on his left forearm that did not need sutures. T63.001A Y92.834 ICD-10-CM Chapter on External Causes of Morbidity: ICD-10-CM Code Description ICD-10-CM Code A patient injured her toe due to bumping into a table while performing household maintenance in the kitchen of her single family home. The patient is an unemployed homeowner, initial encounter. Assign the applicable ICD-10-CM main External Cause, Place of Occurrence, Activity, and Status Codes. W22.8 Y93.E9 Y92.01 M79.676 Cervical strain due to car accident, secondary to loss of control and collision with tree. Patient was the restrained driver. Assign diagnosis code(s) and main external cause code, initial encounter. S16.1ZZA V47.52XA Assign initial encounter for this case: the patient was burned on his face by a fireworks accident that occurred in the neighborhood park. The patient is a high school student and was at the park as part of a student outing from his school. W39.XXXA T20.00XA ICD-10-CM Chapter on Factors Influencing Health Status and Contact with Health Services: ICD-10-CM Code Description ICD-10-CM Code Admission for change of tracheostomy tube and stoma revision. Z43.0 Medical examination of four-year-old child prior to admission to preschool. Z02.0 Presence of cardiac pacemaker and status post aortocoronary bypass surgery. Z09., Z95.0 ICD-10-PCS Code Exercises: Root Operation Group 8: Laparotomy for control of postoperative bleeding in peritoneal cavity Character Code Explanation Section 0 Medical & surgical Body System W Anatomical region, general Root Operation 3 Control Body Part G Peritoneal cavity Approach 0 Open Device Z No device Qualifier Z No qualifier Root Operation Group 8: Open repair of laceration of large intestine: Character Code Explanation Section 0 Medical & surgical Body System D Gastrointestinal Root Operation Q Repair Body Part E Large intestine Approach 0 Open Device Z No device Qualifier Z No qualifier Root Operation Group 9: Posterior spinal fusion of the posterior column at L2-L4 with Bak cage interbody fusion device, open. Character Code Explanation Section 0 Medical & surgical Body System S Lower joints Root Operation G Fusion Body Part 1 Lumbar vertebral Joints, 2 or more Approach 0 Open Device A Interbody Fusion device Qualifier 1 Posterior approach Root Operation Group 9: Construction of a vagina in a male patient using tissue bank donor graft as part of a sex change operation: Character Code Explanation Section 0 Medical & surgical Body System V Male reproductive system Root Operation 2 Change Body Part S Penis Approach X External Device 0 Drainage device Qualifier Z No qualifier Root Operation Group 9: Bilateral breast augmentation with silicone implants, open, cosmetic: Character Code Explanation Section 0 Medical & surgical Body System H Skin & breast Root Operation 0 Alteration Body Part V Breast, bilateral Approach 0 Open Device J Synthetic substitute Qualifier Z No qualifier CPT Evaluation & Management Part I: CPT Description of Procedure CPT Code Patient seen in the physician’s office complaining of a right eye that is itchy, watery, and red. Symptoms began on Saturday. Patient denies any loss of vision. Assign level of “History”. Problem Focused History Alert 16-year-old boy. Temperature: 98.6 degrees F; pulse: 86; respirations: 14; blood pressure: 126/80. Has 2-cm laceration of chin. Assign level of “Physical Examination”. Problem Focused Examination The CC is chest pain. The examination determined: respiration quiet and unlabored; skin with good color, warm and dry, and no rashes; mucous membranes moist; ears and throat clear; lungs with good breath sounds in all fields; rate expiratory wheeze, no rales, no rhonchi; heart regular rate and rhythm with normal heart sounds, no murmur; abdomen soft with no liver or spleen enlargement; and bowel sounds active. Based on this information what is the level of examination? 99203 Dr. Gerald provides preventive medicine services to an established 45-year-old patient who is in good health and has no complaints. Dr. Gerald obtains a comprehensive history, performs a comprehensive examination, and counsels the patient on proper diet and exercise. Assign the appropriate E&M code for this service. 99215 CPT Evaluation & Management Part II: CPT Description of Procedure CPT Code Pediatric inpatient critical care, patient six months of age, third day. Assign Evaluation & Management code 99233 In order to report one critical care code of 99292 a physician must spend between _____________ and 104 minutes with a critically ill patient. 75 minutes When counseling consumes more than half the total visit time, __________ may be used as the criterion for assigning the E/M codes. Time Assign the appropriate E/M code for an outpatient office consultation in which the physician performed a detailed history, a comprehensive physical examination, and medical decision making of moderate complexity. 99254 Combined Inpatient and Outpatient Case Scenarios Ambulatory Health Records: Assign both the ICD-10-CM and CPT Codes, as noted. Description of Procedure ICD-10-CM/CPT Code A 66-year-old patient is seen as an outpatient in the community mental health center and participates in multiple-family group psychotherapy for 45 minutes. Diagnosis: Agoraphobia with panic attacks. List diagnosis and CPT codes F40.01 90849 Description of Procedure ICD-10-CM/CPT Code This 32-year-old female was burned by hot grease in her kitchen one week ago. She is seen in the hospital-based wound clinic for medium sized dressing changes following second-degree burns to both forearms. This is accomplished without requiring anesthesia. Supply ICD-10-CM and CPT code(s). X10.1XXS T22.212 T22.211 16025 Physician-Based Health Records: Assign ICD-10-CM and CPT Codes, as noted Description of Procedure ICD-10-CM/CPT Code An elderly patient is brought to the emergency department by an ambulance due to a cardiac arrest suffered at home. The ED physician provides and documents critical care services to the patient for a total duration of two hours before the attending physician admits the patient to the cardiac care unit. Assign ICD-10-CM and CPT codes for the ED physician including Evaluation & Management code(s): I46. 99291 +99292 Description of Procedure E&M CPT Code Only A 59-year-old male established patient is scheduled for his routine physical examination and this was performed. During this encounter, the physician finds a mass in the abdomen, schedules an abdominal CT scan, and orders laboratory for blood work and a UA. The physician performs a detailed history and an expanded problem-focused examination with medical decision making of moderate complexity. The patient has been a patient of this physician for several years. What E/M code(s) are assigned? 99214 Description of Procedure ICD-10-CM Code Only What diagnosis codes are reported for an initial encounter where the patient is seen for a crushing injury of the left toes, foot, and ankle? He was crushed in a metal rolling mill machine at work. Assign ICD-10-CM code(s): S97.82XA S87.02XA S97.102A Advanced Physician-Based Health Records. Assign codes as indicated: Description of Procedure CPT E&M Code Only An 85-year-old patient of Dr. Smith’s was brought to the clinic from her home after her family failed to get her to respond to their phone calls. She was poorly nourished, dehydrated, and confused. Dr. Smith admitted her to the hospital to stabilize her, then discharged her to home the next day. Assuming that all documentation guidelines for each level of service have been met, assign the correct CPT codes for Dr. Smith’s services to the hospital 99222 99239 Description of Procedure ICD-10-CM and CPT E&M Codes A patient presents to the neurology clinic for assessment of apraxia at the request of her primary care physician. The patient has a history of CVA and has expressive aphasia. She is unable to carry out purposeful movements, even though she has normal muscle tone and coordination. A full assessment is performed using the Boston Diagnostic Aphasia Examination including interpretation and report (one hour). The consulting neurologist conducts a detailed history and examination, performs medical decision making of low complexity, and dictates a complete report to the requesting physician, along with the finding of the aphasia assessment. Provide diagnostic codes as well as CPT and Evaluation & Management code(s). 99203 99239 Submitting your work: Submit your Assignment to the appropriate Dropbox. To view your graded work, come back to the Dropbox or go to the Gradebook after your instructor has evaluated it. Make sure that you save a copy of your submitted work. Grading Rubric for Part One Writing Assignment: Assignment Requirements 50 Points Paper addresses the following: Points possible Points earned by student A. What is Clinical Document Improvement (CDI) and its purpose? What is the impact of a good CDI program for both inpatient and outpatient facilities? What is the role of coding auditing and what does it entail? 0-10 0-10 0-10 B. - An original and insightful “take away” from the documents reviewed and how it how it applies to the relationship between CDI, the principles of auditing, and quality coding practices. 0 -20 Total (Sum of all points) 50 Points deducted for spelling, grammar, and/or APA errors. Adjusted total points Unit 9 Grading Rubric: Assignment Requirements Points – 176 Total Points Points possible Points earned by student PART TWO: ICD-10-CM Mental and Behavioral: (4) 0-8 PART TWO: - ICD-10-CM Nervous System (4) : 0-8 PART TWO: - ICD-10-CM Chapter on Injury: (3) : 0-6 PART TWO: - ICD-10-CM Poisoning and Certain Other Consequences (3) : 0-6 PART TWO: ICD-10-CM External Causes of Morbidity (3): 0-6 PART TWO: Factors Influencing Health Status (3): 0-6 PART TWO: - ICD-10- PCS Group Eight (2) : 0-10 PART TWO: - ICD-10-PCS Group Nine (3) : 0-15 PART TWO: - CPT Evaluation & Management Part 1 (4) : 0-8 PART TWO: - CPT Evaluation and Management Part II (4) : 0-8 PART TWO: Ambulatory Health Records (2): 0-10 PART TWO: Physician-Based Health Records (3): 0-15 PART TWO: Advanced Physician-Based Health Records (2): 0-20 PART One: Points from Writing Assignment (See separate Grading Rubric) 0-50 Total (Sum of all points) 0-176 Points deducted for spelling, grammar, and/or APA errors. Adjusted total points
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