Unit outcomes addressed in this Assignment:
Apply diagnostic and procedure codes according to current guidelines using common classification systems, taxonomies, nomenclatures and terminologies
· Identify the documentation needs that relate to quality coding practices
· Discuss the role of coding with the key features of an electronic health record (EHR) system and clinical document standards.
· Discuss the importance and relevance of Computer-Assisted Coding along with coding problems that may arise.
Course outcome(s) practiced in this unit:
HI253-5: Appraise a health record for deficiencies needed for quality coding (Bloom’s Level 4)
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)
· Clinical Care Classification (CCC)
· CPT, DSM, RxNorm
· LOINC, SNOMED CT
Part 1: Coding Scenario Worksheet (coding practice): Complete the coding scenarios worksheet indicated in Part 1 below by indicating the appropriate codes.
Part 2: Nuance Quantim Physician Query Activity: Please access the AHIMA’s Virtual Laboratories (VLabs) at http://academy.ahima.org/ website. Within the Virtual Lab (My Learning), go to the Virtual Lab applications and open the Nuance Quantim Encoder application and complete the Nuance Quantim #6 Activity on Physician Query activity with a passing score of 100% and appropriately identify the documentation needs that relate to quality coding practices. Answer the provided questions and submit a screen shot of your completed Physician Query activity in the Part 2 section of the Assignment Worksheet.
Part 3: Electronic Health Record and Coding Systems:
A. VistA Simulation: Please access the AHIMA’s Virtual Laboratories (VLabs) at http://academy.ahima.org/ and follow the instructions under Part 3. Once completed, take a screen shot of the completion page and attach to the appropriate Part 3 section of the Assignment Worksheet. Remember to review the VLab instructional sheet in Doc Sharing if you trouble navigating.
B. EHR and Coding Resources Comparison Table: Answer the question indicated and support your answer by providing a table to include where the resource would be located and how best to access.
Part 4: Computer-Assisted Coding: Refer to the information from your Unit 10 Discussion Board and provide your answers/discussion in the Part 4 section of the Assignment Worksheet.
· Your assignment worksheet may contain citations and references, and if used, should utilize APA style, with no more than 10% quoting. Please use paraphrasing, in-text citation, and referencing.
· Correct spelling and grammar should be utilized throughout and if required, the answers provided in complete sentences.
· The word count should reflect the following