MCCG240 EVALUATION AND MANAGEMENT SERVICES

Coding Audit

Email

Course, Program, and Institutional Outcome(s) Assessed:

This assignment measures your ability to meet the follows outcome(s):

· Course outcome: Evaluate E/M codes assigned to patient encounters in health records for accuracy and make any necessary corrections.

· Program outcome: Abstract information from medical charts to assign the correct diagnosis (ICD-10), procedure (CPT), and supply (HCPCS Level II) codes in a variety or medical situations.

· Relational Learning: Transfer knowledge, skills, and behaviors acquired through formal and informal learning and life experiences to new situations.

Relevant Background Information:

Coder

s will audit charts already coded to determine the accuracy of the codes assigned.

This is a critical skill that you need to develop to help you understand the complexity of medical coding. 

Assignment Purpose:

This assignment asks you to review real patient medical records and the codes already assigned to these and determine if the assigned codes are correct, following the Official ICD-10 Coding Guidelines and CPT Coding Guidelines.

Assignment Directions:

Imagine that you are a coding supervisor and are worried about a potential OIG audit. Therefore, you decide to review high level E/M code assignments by your staff of three coders. The goal of this review is to ensure the documentation supports the codes assigned by your coding staff.

Follow the steps below to complete this assignment:

1. Review the following cases from your You Code It! textbook. Imagine that these cases were coded by your staff as indicated below.

2. After thoroughly reviewing each patient case, assign all appropriate ICD, CPT, and/or E/M codes to the patient record. You may choose to use the code books or any encoder to do this.

3. Compare your codes to those assigned by the coders. Determine if the code assignments from the coders are accurate.

4. If the codes are inaccurate, provide rationale to support your code choice.

5. Create a chart or table in Microsoft Word that accomplishes the following:

a. Portrays the code assignments from the coders compared to your code assignments for all patient cases.

b. Provides rationale for any differences between the codes identified by you and the coders.

c. Summarizes the accuracy rate of each coder.

d. If you need help with creating charts and tables in Word, see #9 below.

6. Write an email to your coding staff that explains the following:

a. Summarizes the accuracy rate of your coding staff as a whole department.

b. References the chart you created in Step #5.

c. Describes the potential consequences that could have occurred if you had not found and corrected the errors in their coding.

d. Provides the next steps you will take to ensure their coding is more accurate in the future.

7. Review the attached rubric to determine how your work will be graded.

8. Submit your work by the designated due date. Note that you will submit both the chart and the email, either in one Word document or as two separate documents.

9. Refer to the following resources if you need assistance with creating charts and tables in Word. To view the links below, hold Ctrl while clicking on the link, or copy and paste the link into your web browser.

a. The following video shows how to create a chart in Word:

b. The following link contains written directions to add a chart to Word:

https://support.office.com/en-us/article/add-a-chart-to-your-document-in-word-ff48e3eb-5e04-4368-a39e-20df7c798932

c. The following link contains both a video and written directions on how to add a table in Word:

https://support.office.com/en-us/article/insert-a-table-a138f745-73ef-4879-b99a-2f3d38be612a

MCCG212 Advanced ICD Diagnosis Coding

ICD-10 Patient Coding Scenarios

Rubric

25.4-21

20.9-19.5