HIT 2300 IIT Music Theory Computer Assisted Coding Patient Records Discussion

Question Description

For this assignment, you will learn about Computer Assisted Coding and practice using the simulated computer assisted encoder (CAC). Many encoders now have this feature to assist coders with coding. The CAC will use natural language processing to suggest diagnoses and procedures/surgeries that should be coded. The coder then acts as an editor and determines which suggested codes should actually be coded on the chart.

undefined

The Computer Assisted Coding encoder will scan the record and highlight words in an EHR that it thinks should be coded.The coder then will evaluate each shaded word to determine if that highlighted word is part of this case and should be coded or whether it should not be coded. Things to consider are:it is part of this current care/case, is it a part of an old history not related to this case, is it part of a comment that does not apply to this case, or is it part of a physician copy and paste from an old record, etc.

undefined

Part One:

undefined

A. Read the following report from a patient record that has been processed with computer assisted coding (CAC) encoder software.

undefined

B. Determine any areas of inaccuracy in the CAC codes identified in the list below.

undefined

C. Following all official coding guidelines, recommend corrections to the CAC code assignment below.What code should be the principal diagnosis and which codes should be the secondary diagnoses?Should any codes not be used?Sequence codes accordingly and indicate those that should not be used for this case.

undefined

D.Make and submit your own list of correct codes indicating any below that should be deleted, list in correct order any codes that should be sequenced differently and explain why.Explain if you changed the principal diagnosis and why.Indicate which official coding guidelines that you used in making these decisions.

undefined

Mr. Mayberry is a 62-year-old Caucasian male admitted with chest pain. He states that he developed this pain after lifting heavy objects while cleaning his garage. He ranks his pain as an 8 out of 10 on the pain scale.He has no arm or jaw pain.

He has been treated for hyperlipidemia, and hypertension, on medication for both conditions for the last 10 years. Past history reveals that 11 months ago, he suffered an acute myocardial infarction and was treated with stents.

Today, an EKG was performed and cardiac enzymes drawn. All results were normal. The patient

exhibited the pain upon movement and palpation at the chondrosternal joint and a final

diagnosis of sprain was determined.

Codes assigned by CAC encoder:

R07.9

I21.3

R68.84

S23.421A

I10

E78.5

Resources:

https://www.himss.org/news/computer-assisted-codin…