Laboratory Exercise 2: Compilation of Electronic Medical Records

Domain I.: Data Content Structure And StandardsSubdomain I.A.: Classification SystemsCompetency: Evaluate the accuracy of diagnostic coding (BL5)Curricula considerations: Principles and applications of Classification Systems, Taxonomies, Nomenclatures, Terminologies, and Clinical Vocabularies; Principles and applications of classification, taxonomies, nomenclatures, terminologies, clinical vocabularies, auditing Principles and applications of diagnostic and procedural grouping (DRG, MSDRG); Principles and applications of diagnostic and procedural grouping (DRG, MSDRG)

Subdomain I.B.: Health Record Content and DocumentationCompetency: Analyze the documentation in the health record to ensure it supports the diagnosis and reflects the patient’s progress, clinical findings, and discharge status (BL4)Curricula considerations: Content of health record; Documentation requirements of the health record

Domain III.: Infomatics, Analytics And Data UseSubdomain III. A.: Health Information TechnologyCompetency: Utilize software in the completion of HIM processes (BL3)Curricular considerations: Record tracking, ROI, coding, grouping, registries, billing, quality improvement, imaging Electronic Health Records EHR, Personal Health Record PHR, and document imaging

Domain V.: ComplianceSubdomain V. B.: CodingCompetency: Analyze current regulations and established guidelines in clinical classification systems (BL4)Curricula considerations: Severity of illness systems (Present on admission); UHDDS guidelines, Coding Specialty systems

Subdomain V. D.: Clinical Documentation ImprovementCompetency: Identify discrepancies between supporting documentation and coded data (BL3)Curricula considerations: Clinical outcomes measures and monitoring; AHIMA CDI toolbox; Professional communication skills; Clinical documentation improvements (Physician Role, HIM Role in CDI)

Domain VI: LeadershipSubdomain VI.H.: EthicsCompetency: Comply with ethical standards of practice (BL5)Curricular considerations: AHIMA Code of Ethics

Description: This exercise consists of five parts. The expected completion time is 40 hours. This is 20% of the grade. Due: Week 12

Part I – Medical Necessity. Each student will select a specific body system or diagnosis that is not identical from other students. Use online search engines to gather information of the selected body system / diagnosis/ and corresponding treatment /procedures. The diagnosis can be with comorbidity or complication or without comorbidity / complication. This activity will allow the students to understand the concept of medical necessity of the diseases / diagnosis / severity of illness (ICD-10-CM coding) to the services provided to the patient (CPT / HCPCS coding). student will navigate the site to search for medical records based on the selected body system or from CCS Exam Preparation Case Analysis Practice Questions, Exam 1 and Exam 2.

Below is the list of different services provided to a patient complaining of lump, swelling, and nipple discharge of left breast.

Type of Service Reason for visit / admission Type of Medical Record Section of CPT manualOffice visit Lump left breast, swelling, nipple discharge SOAP Progress Note Evaluation and ManagementReferral for mammogram / ultrasound Lump left breast Radiology Report Radiology sectionReferral for biospy Lump left breast Pathology Report Pathology SectionReferral for biopsy Lump left breast Operative Report Surgery SectionInpatient for mastectomy and cosmetic surgery Left breast CA Operative Report, Progress Note, Laboratory, EKG, Anesthesia Surgery, E/M, Anesthesia, Laboratory, Medicine,

Part II – Format and Documentation Requirements of Electronic Medical Records. Each student will design and complete the format and documentation requirements of each electronic medical record. Each student will organize a minimum of six sections of a medical record for one patient based on the selected body system or severity of illness, which is not identical from other students. The list will include the following: Completed Operative Report from Homework 3 using Textbook Appendix B; Completed diagnostic tests such as Radiology Report, Laboratory report, Pathology Report, EKG Report or other diagnostic tests from Homework 5 CCS Exam Preparation cases, and Completed SOAP Progress Note. Use case analysis procedural coding template for CPT/HCPCS. Review / highlight the documentation supporting procedures and assign correct codes according to clinical documentation. Due date: Week 12

Part III – Documentation Review and Computer Assisted Coding. Instructor will review and provide thenecessary recommendations to Part II. Use Encoder Pro software to verify the accuracy of procedure codes, review NCCI edits for multiple procedures and apply modifiers to bypass edits. Print the Encoder Pro NCCI edits before and after the application of modifiers to bypass edits as proof of compliance with coding guidelines. An explanation of the use of modifier is included.

Part IV – Create a Table to compare and contrast the format and documentation requirements of the compiled electronic medical records. Create a table to compare and contrast APC status indicators or ASC payment indicators of the CPT procedure codes. The tables must be created in Microsoft Word, and typed in Times New Roman, size 12 font. Justify the application of different APC status indicators or ASC payment indicators for reimbursement in health care

Part V – This report must be typed in Times New Roman, size 12 font, double spaced and approximately 2-3 pages in length. It must include: a) Relate the importance of documentation in patient’s quality of care and reimbursement. b) Determine the need for validation of codes using clinical information from the health record. c) Select measures to monitor coding quality in a healthcare setting. d) Create a mechanism for reporting and resolving discrepancies between coded data and clinical documentation. e) Relate the importance of computer assisted coding (Encoder Pro) to coding quality and facility reimbursement. f) Justify the importance of the application of AHIMA Code of Ethics. Indicate the AHIMA code of Ethics applicable for this case.

Objectives:By the end of this course, students will be able to:

1 Apply correct coding and guidelines to the Surgical section, Radiology section, Pathology/Laboratory section, Medicine section, Anesthesia section and Evaluation and Management of CPT. (BL 3)2 Use case analysis procedural / diagnostic coding template to assign the accurate procedural codes (BL3)3 Identify documentation supporting diagnosis (if applicable) and procedure codes (BL3)4 Apply information learned to assign modifiers in various sections of CPT. (BL 3)5 Determine the application of different APC status indicators or ASC payment indicators for reimbursement in health care (BL 5)6 Create a table listing the procedure codes with APC status indicator for each procedure(BL6)7 Apply APC Status Indicator and identify the procedures that are paid under OPPS. (BL 3)8 Abstract clinical documentation supporting diagnosis and procedure codes and compare with coded data (BL3)9 Identify the discrepancies between coded data and supporting documentation (BL3)10 Relate the importance of documentation to patient’s quality of care and reimbursement (BL5)11 Determine the need for validation of codes using clinical information from the health record (BL5)12 Use Encoder Pro software to identify the correct CPT /HCPCS Level II procedure codes (BL313 Use Encoder Pro to connect LCD Policy /NCD Policy with medical necessity (BL3)14 Print Encoder Pro NCCI edits and apply CPT / HCPCS Level II modifier(s) to bypass edits (BL4)15 Relate the importance of computer assisted coding (Encoder Pro) to coding quality and facility reimbursement (BL5)16 Justify the importance of the application of AHIMA Code of Ethics (BL5)

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Laboratory Exercise 2: Compilation of Electronic Medical Records

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