HI 253 Purdue University Global The Skeletal System: When Problems Arise Essay HI253: Medical Coding I Topic 2: Team Medical Record Review Audit Assignme

HI 253 Purdue University Global The Skeletal System: When Problems Arise Essay HI253: Medical Coding I

Topic 2: Team Medical Record Review Audit

Assignment Instructions: You have been assigned to one of four audit teams.
For Part 1 of the Discussion board, you will review the medical record identified in your team area, identifying the diagnosis and/or procedure codes specified. The medical record document is available in the Medical Records for Review folder in Course Documents. Submit your chart review findings to your team discussion area by Saturday night, using Template 1 below.

Part 1: Code the Case

Access your team’s case in the Medical Records for Review folder in the Course Documents area of the course Table of Contents. All team members will be assigning codes for the same chart.
Review the medical record and identify the diagnosis and/or procedure codes specified on the record.
Enter your chart review findings by completing Template 1 below.
Copy and paste your findings into the DB as your initial post by Saturday midnight.

Template 1: Initial Chart Review

I reviewed chart # _____ for an _______ visit dated _________.

The patient’s principal diagnosis was _________________________

Additional reported diagnoses were __________________________

Services provided on the visit included ________________________

Example Initial Post:

I reviewed chart # 35587 for an outpatient surgery visit dated 07/01/YYYY.

The patient’s principal diagnosis was acute appendicitis, unspecified (K35.80)

Additional reported diagnoses were type 2 diabetes mellitus without complications (E11.9)

Services provided on the visit included laparoscopic appendectomy (44970)

Participation Expectations: Please engage on this topic throughout the unit by posting one main response by Saturday midnight. There are no specific word counts for this discussion board assignment.

SC121: Human A&P I

Topic 2: The Skeletal System: When Problems Arise

The skeletal system is composed of 206 named bones in the body. The bones form the framework of the body, but also have many other important functions such as mineral storage, protection of vital organs and blood cell production. As this system is so complex, much can go wrong and have an impact on the overall functioning of the body.

This week, you will research a disorder or disease of the skeletal system – this can be related to the overall system, the axial skeleton, or the appendicular skeleton (list the name of the disorder in the subject line of your main post). Please do not discuss any joint-related issues – no credit will be given for off-topic responses. Since osteogenesis imperfecta was already discussed in Unit 4, please do not choose this topic for this Discussion Board.

What disorder/disease did you choose to write about?
Which part of the skeleton does this disorder/disease affect?
What are the symptoms of this disorder/disease?
What are the long-term effects of this disorder/disease?
Describe some of the current treatments available. Are there any new treatments on the horizon?

How would you cope if you had this issue and which treatment option would you choose? Why? HI253 UNIT 7 TEAM MEDICAL RECORD AUDI
Comments to student are entered here.
Part 1 – Team
Collaborative Space:
Student engages
teammates through
Part 2 – Medical
Record Review and
Audit: Student
demonstrates ability
to accurately extract
coding information
from medical record,
Part 3 – Overall
Engagement:
Student’s
contributions to team
discussion are
composed in formal
Introductory
0-1
No initial post or
classmate posts to Team
space (0).
Emergent
2
Submission is late and
does not include the
required number of
posts.
Two of the following
apply: Student
incorrectly extracts
No record review or audit
diagnosis and/or
posts (0).
procedure codes from
medical record review;
Audit of team member
Significant errors in
spelling and/or grammar.
Poor spelling and
Major flaws in writing
grammar are apparent.
mechanics and
formatting.
PC1.1: Engage in a team setting with professional integrity and respect.
MEDICAL RECORD AUDIT GRADING RUBRIC
Total available points =
Practiced
3
One of the following
applies: Submission is
late; does not include
the required number of
One of the following
applies: Student
incorrectly extracts
diagnosis and/or
procedure codes from
medical record review;
Audit of team member is
Proficient/Mastered
Score
4
Student posts one main
response by Saturday and at
4
least one reply post by
Tuesday to the team
Student accurately extracts
diagnosis and/or procedure
codes from medical record
4
review. Audit of team
member is thorough and
accurate.
Uses Standard American Consistently uses Standard
English with rare errors American English with rare
and misspellings.
misspellings.
ntegrity and respect.
4
20
Weight
Final Score
50%
2.00
40%
1.60
10%
0.40
100%
4.0
Final Score
20.0
Percentage
100%
100%
5
HCPCS Coding
HCPCS
• Stands for Healthcare Common Procedure
Coding System. Pronounced “HIC-PICKS”
• 5 digit Alphanumeric codes beginning with A
through V- in textbook
• Used to describe services, supplies and
drugs not described in CPT
• Required by Medicare
• Also used by most insurance companies
that understand
the value of accurate codes
July 25, 2020
Copyright Rasmussen, Inc. 2011. Proprietary and Confidential.
2
How are HCPCS
codes used?
• A patient is seen in the hospital for severe
back pain
• Dr orders morphine as needed
• Patient requests pain med
• Nurse enters the morphine
administration into the EMR
• HCPCS code for Morphine, J2270, (and the
charge) are transferred to the patients bill
• This is how itemized bills are created
HCPCS in 3M
Encoder
To access 3M from your computer, go to:
Website: 3m.ahima.org
Username: KAP001
Password: AHIMA#77
NOTE: Username and Password are case
sensitive which means you enter it as it is
given(all caps). Also this is a school wide
username and password, under no
circumstance are you to change the username
or password.
Finding
HCPCS in 3M
Encoder
3m.ahima.org
User name: KAP001
Password:
• Enter a random age in the age field on the left side
of the main screen
• On the left side of the screen, select the Product
drop down arrow
• Select HCPCS/CPTFINDER
• Hit continue
• On the Patient Code Summary screen, click on Add
Procedure
• In the Enter Keyword or Code, start to enter what
you are searching for
• 3M will begin to bring up options to choose from
• Select from the choices as they apply to your
product/supply
• http://www.stratishealth.org/index.html
Finding HCPCS
Online: Free
sites that you
can look up your
codes
• https://www.dmepdac.com/dmecsapp/do/sea
rch
• https://www.pgmbilling.com/hcpcs-lookuptool/
• You can also just Google what
you are looking for. Example
search term: HCPCS code for
walking cane, fixed, with tip:
E0100
HCPCS Updates
• HCPCS publishes its coding reference
once a year, in the fall around October.
Publications effective date is January 1 of
the next calendar year
• It is important to know HCPCS updates its
code sets 2 MORE TIMES throughout the
year. Updates can be found on the CMS
website.
• These updates occur in April & July
HCPCS J Codes
• J Codes and the Table of Drugs
• Drugs are listed by generic name
unless the drug is known by is its
brand name only in HCPCS
• You will have to research for generic
names if unknown……..
• Remember that GUESSING is NOT a
part of CODING
• Once You have located your
proper drug/medication:
HCPCS Table of
Drugs
July 25, 2020
• You must identify the dosage set
for that code set
• You must identify the method of
administration for that medication
as well
• Understand that the medications
on the drug table are listed in
milliliters (mL) or in cubic
centimeters
• Remember that one cc=one mL
Copyright Rasmussen College, 2012. Proprietary and Confidential.
9
QUESTION
• J7506 Prednisone, oral, per 5mg
• The physician provides the patient with
20 tablets of Prednisone to be taken
orally, 5mg tablets. How would you code
this?
• J7506
• J7506 x 5
• J7506 x 10
• J7506 x 20
ANSWER
• Proper code would be D. J7506 x20 as you code for each tablet dispensed.
• Prednisone is listed as oral, per 5mg which describes the dose of the tablets. The physician
is providing a 20 tablet supply for this medication.
• What if 4, 10mg tabs were dispensed?
•
4 10mg=8 mg
HCPCS &
Medicare
• HCPCS will affect your coding standards
when it comes to Medicare patients.
• A coder should refer to the Medicare Fee
Schedule Database to assist with this
process
• When reviewing the database, any codes
with an “I” in the status code will indicate
that a HCPCS code will need to be attached
in place of a CPT code
• Physician orders 40 U of Heparin
sodium, IV administration.
QUESTION
• HCPCS code is:
• J1642 Injection, Heparin Sodium
(Heparin lock flush), per 10 units.
• How would you report this medication?
ANSWER
• Code: J1642 x 4
• Heparin is a blood thinner and is also used to flush IV ports/access sites. The code set
is for 10 units per dosage.
• This scenario is calling for 40 units. Code would be J1642 x4 for this medication order
• To complete this coding scenario, you would also code for the method of administration.
• Remember for every product there is a method of administration to be reported
7
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MRN
–
..
..
Sex
Age
65
DOB
Female
–
SURGEON
Signed
op Note
…
Servicedate:
05/30/20142:35 PM
.. o
PATIENTNAME:
MRN:
DATE OF SERVICE: 05/30/2014
PREOPERATIVEDIAGNOSIS:
POSTOPERATIVEDIAGNOSIS: Intractable epilepsy.
OPERATIONPERFORMED: Replacement of a VNS generator for vagal nerve stimulator with
intraoperative interrogation of device.
SURGEON: The attending and surgeon is Dr.
ASSISTANTSURGEON:
ANESTHESIOLOGIST:
ASSISTANTANESTHESIOLOGIST:
ANESTHESIA:
POSTOPERATIVEDIAGNOSIS: Intractable epilepsy.
INDICATIONS: The patient is a woman with a long history of intractable epilepsy with a vagal nerve
stimulator implant in place. The generator was nearing the end of its lifespan and she was
recommended to undergo replacement of generator.
FINDINGSAT SURGERY: No abnormalities other than expected postop changes.
DESCRIPTIONOF PROCEDURE: The patient was brought to the Operative Suite. General
anesthesia was induced . An endotracheal tube was placed . Lines were placed. The left chest was
sterilely prepped and draped. The old incision was infiltrated with local anesthetic. A skin incision was
made with a #1 0blade. Bovie hemocautery was used to dissect through subcutaneous fat and to
open the fibrotic capsule around the old generator. The generator was brought out of the chest area .
The Allen wrench was used to remove the leads from the old generator. The new generator was
obtained . Itwas a model 104, and it was attached to the leads with the Allen wrench. The new
generator was then placed in the subcutaneous pouch and anchored with a 2-0silk suture. The
wound was irrigated with bacitracin irrigation. The computer wand was placed in a sterile sleeve and
the generator was interrogated and programmed with the patient code and date. Lead impedance was
tested and found to be okay. The wound was closed with 3-0 Vicryl suture and runni ng subcuticular 40 Monocryl suture with Steri-Stripsand a sterile dressing over th at. The patient was transported to the
recovery area in stable cond ition .
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1 of 4
MRN
DOB
Sex
Female
–
Physician
A ssistant
Signed
Progress Notes
Age
65
Service date:
05/30/2014 10:33AM
Relatedenc ounter: Office Vis it frorn 5/30/2014in
CHIEF COMPLAINT End of battery life for
generator
HISTORYOF PRESENTILLNESS:
65 y.o. femaleright handed who
is a
presents to clinictoday for Pre-OpEvaluationfor replacement of VNS generator.
with mentalretardation and intractable epilepsy. Her VN S was lastchanged in
resident of l
2008.The patient currentlyreports their pain is a level 0/10
BP 120/78 Pulse 64 Temp(Src) 35.9 oc (96. 7 oF) (Temporal) Resp 16
Past MedicalHistory
Diagnosi s
GERD (gastroesophageal refluxdisease)
MR (mental retardation)
Seizures
Arthritis
Glaucoma
Osteoporosis
Pseudophakiaof both eyes
Cornea edema lefteye
PastSurgical History
Date
10/25/2013
10/25/2013
Laterality
Procedure
Eye surgery
Vagal nerve stimulation
Vagal nerve stimulation
Total knee arthroplasty
Date
3/8/2000
4/3/2008
5/4/2001
RIGHT.
11/13/200
Revision total knee arthroplasty
3
RIGHT.
8/25/2003
Knee surgery
RADICAL RESECTIONRIGHT DISTALFEMUR, REMOVALRIGHT TKA, RIGHT KNEE
ARTHRODESISWITH AN INTRAMEDULLARY RODFROMTHE PROXIMALFEMUR
DOWNTO THE DISTAL TIBIA
History
Soci al History
Marital Status :
Spouse Name:
Number of Children
Years of Education:
Single
N/A
N/A
N/A
Occupational History
Not on file.
Social Hi story MainTopics
Smoking status:
Smokelesstobacco :
AlcoholUse:
Drug Use:
about: blank
Never Smoker
Never Used
No
No
8/14/2014
2 of 4
SexuallyActive:
OtherTopics
Concern
Not on file
Social History Narrative
No narrative on file
Cell Phone: 352-955-5000
Allergies
Allergen
Reactions
Tegretol (Carbamazepine)
Other(See Comments)
UNKNOWN
Current Outpatient Prescriptions
Medication
bisacodyl (DULCOLAX)5 MG
EC tablet
bisacodyl (DULCOLAX)5 MG
EC tablet
Sig
Dispense
Take 15 mg by mouth daily as
needed. Give@@ 5 pm
Take 5 mg by mouth . 4 tablets 20
mg by mouth @@ 8 am 2 days
prior to colonoscopy appt
calcium carbonate-vitamin d 600- Take 1 Tablet by mouth 2 times
400 MG-UNITTABS
daily.
clonazePAM (KLONOPIN) 1 MG Take 1 mg by mouth 2 times
tablet
daily. Morning and@@ 5 pm
divalproex (DEPAKOTE)250 MG Take 750 mg by mouth 2 times
EC tablet
daily .
docusate sodium (COLACE) `100 Take 100 mg by mouth 2 times
MG capsule
daily.
Place 1 drop into the right eye 4 5 mL
ketorolac (ACULAR LS) 0.4 %
SOLN
times daily .
lamoTRigine (LAMICTAL) 100
Take 125 mg by mouth 2 times
MG tablet
daily.
levetiracetam (KEPPRA) 1000
Take 1,500mg by mouth 2 times
MG tablet
daily.
LORazepam (ATIVAN)2 MG/ML Inject4 mg as directed as
injection
needed . x1 dose for prolonged
seizures lasting more than 2
minutes and the person is still
seizing or a cluster of 3 or more
seizures within 1 hr time or 5 or
more myoclonic jerks within 1
minutes
LORazepam (ATIVAN)2 MG/ML Inject4 mg as directed as
injection
needed. Repeat 4mg IM injection
as needed x1 dose if the seizure
has not stopped 10 minutes after
the 1st dose
meloxicam (MOBIC) 15 MG
Take 15 mg by mouth daily.
tablet
As instructed. 3 drops into each
MINERALOIL HEAVY
ear @@ bedtime 3x week
Monday,Wednesday, and Friday
Multiple Vitamins-Minerals
Take 1 Tablet by mouth daily.
(MULTIVITAMIN) WITH
MINERALS)TABS
ranitidine (ZANTAC) 150 MG
Take 150 mg by mouth nightly.
tablet
senna (SENOKOT)8.6 MG
Take 17.2 mg by mouth every
TABS tablet
evening.
about: blank
Refill
8/14/2014
Page 3 of 4
sodium chloride(MURO)5%
ophthalmic ointment
timolol (TIMOPTIC)0.5%
ophthalmic solution
travoprost, benzalkonium,
(TRAVATAN) 0.004%
ophthalmic solution
Place0.25 inches into the left
eye. bid
place 1 drop into the right eye 2
times daily.
Place1 drop into the right eye
nightly.
No current facility-administered medications for this visit.
REVIEWOF SYSTEMS:
Constitutional : No problems
Eyes: Glaucoma
ENT/Mouth : No problems
Cardiovascular: Leg pain while walking and Swelling in hands or feet
Respiratory: No problems
Gastrointestinal : GERD
Genitourinary: Incontinence
Musculoskeletal : Arm or leg pain , Arm or legweakness and Arthritis
Integumentary: No problems
Neurologic: Seizures
Psychiatric: No problems
Endocrine: No problems
Hematologic/Lymphatic: No problems
Allergic/Immunologic: No problems
PHYSICALEXAMINATION:
2nd Cranial Nerve:
3rd, 4th, 6th Cranial Nerves:
5th Cranial Nerve:
7th Cranial Nerve:
8th Cranial Nerve:
9th, 10th Cranial Nerves:
11th Cranial nerve:
12th Cranial nerve:
blinksto threat
Dysconjugate gaze with opacification of cornea on left
grimaces to touch
full and symmetrical facial movement
hears finger rub well bilaterally
Opens mouth to command
Kyphotic posture, head tiltto right
normal tongue movement
well developed, well nourished , in no apparent distress and seated in
Constitutional:
wheelchair, right knee extended
Eyes:
Dysconjugate gaze, opacification on leftcornea
Head:
normocephalic, atraumatic
Mouth/Throat:
periodontal disease noted and moist mucus membranes
Neck:
no adenopathy ,no palpablethyroid tissue and supple, no adenopathy, no
JVD, no bruits , no thyromegaly
Chest:
clearbilaterally
Cardiac:
normal rate and regular rhythm
no edema and compression hose in place
Vascular:
Abdomen :
abdomen is soft without significant tenderness and bowel sounds
present
exam deferred
Genital:
deformities: right knee
Extremities :
no lymphadenopathy
Lymph nodes :
Decreased ROM right knee
Musculoskeletal :
mental status awake, looking around, speech dysarthric, alert and oriented x
Neurologic:
person and home is
Followssimple commands
about: blank
8/14/2014
Page 4 of 4
Skin:
M usc e s
no rashes or significant lesions,no petechiae and no bruising
th
reng
Deltoid
Biceps
Triceps
Wrist Ext
Grip
Psoas
Quadriceps
TibialisAnt
EHL
Gastoc
5/5
5/5
5/5
5/5
Right
5/5
5/5
5/5
5/5
0/5
5/5
Sensation:
ASSESSMENT:
5/5
5/5
5/5
5/5
5/5
5/5
5/5
5/5
5/5
5/5
Left
no decrease in sensation, arms and legsto touch
End of battery lifeVNS generator
PLAN : replaceVNS generator.
has dicussed the risks and benefits of this surgery with
The patient understands and wishes to proceed. The consent is signed and on the chart. i
has been instructed to be NPOafter midnight. The patient has been provided with Cida Stat
soap and instructed to shampoo and shower head to toe , both the night before surgery and the
morning of surgery before coming to the hospital. Pre- and post operative teaching have been begun.
The patient was educated on what level of pain to expect postoperatively and what pain management
modalities to expect.
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8/14/2014
1 of 1
..
Med’Ication Ad ministraon
ti
Rep_ort for
as of 08/15/14 0857
1 Day
3 Days
7 Days
10 Days Today
Legend
Medications
05/21 05/22 05/23 05/24 05/25 05/26 05/27 05/28 05/29 05/30
Discontinued Medications
Medications
05/21 05/22 05/23 05/24 05/25 05/26 05/27 05/28 05/29 05/30
1307
0.9 % NaCl infusion
Rate: 10 mUhr Freq: CONTINUOUS Route: IV
Start: 05/30/14 1215 End: 05/30/141708
u
–
1352
()
1405
()
Medications
05/21 05/22 05/23 05/24 05/25 05/26 05/27 05/28 05/29 05/30
by J
8/15/2014 8:57:46 AM

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