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MCCG240 EVALUATION AND MANAGEMENT SERVICES

Computer Assisted Coding Audit

Code-A-Note Review Notes

Chapter 24 Olivia Fernandez

	Code Books		Code-A-Note		Explanation of Differences
	First Listed Diagnosis
	Secondary Diagnosis or Diagnoses
	Principal Procedure
	Secondary Procedure(s)

Code-A-Note Review Notes

Chapter 24 Lance Desimini

Code Books

Code-A-Note

Explanation of Differences

First Listed Diagnosis

Secondary Diagnosis

or Diagnoses

Principal Procedure

Secondary Procedure(s)

Code-A-Note Review Notes

Chapter 25 Peter Bartlett

Code Books

Code-A-Note

Explanation of Differences

First Listed Diagnosis

Secondary Diagnosis

or Diagnoses

Principal Procedure

Secondary Procedure(s)

MCCG240 EVALUATION AND MANAGEMENT SERVICES

Computer Assisted Coding Audit

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

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

· Course outcome: Synthesize results of aggregate coded data.

· Program outcome: Analyze the results of aggregate coded data to report findings and trends.

· Institutional outcome – Quantitative & Scientific Reasoning: Follow established methods of inquiry and mathematical reasoning to form conclusions and make decisions.

Relevant Background Information:

Coders often have additional job duties besides billing and coding. One of these duties is software evaluation. Because it is coders who use EHR software, encoders, or other health care software, they are often asked to evaluate software options prior to the administration making a purchase.

Assignment Purpose:

This assignment asks you to review code accuracy assigned from a computer assisted coding program to determine the benefits of using such a program in a medical office.

Assignment Directions:

Imagine that you are a coding supervisor and are tasked with finding a new encoder product. You have recommended that the administration consider purchasing an encoder that has computer assisted coding (CAC) because it would reduce the amount of time the coders need to code the physician’s documentation, thus encouraging a quicker reimbursement. You prefer Find-A-Code because of its Code-A-Note program. The administration has asked you to test out Code-A-Note within Find-A-Code and report your findings and a recommendation of whether or not to purchase this encoder.

You want to base your review on the accuracy of Code-A-Note, so you decide to try coding three patient charts in the encoder to determine how accurate it is before making your recommendation.

Follow the steps below to complete this assignment:

1. Review the following cases in your You Code It! textbook:

a. Chapter 24: Olivia Fernandez

b. Chapter 24: Lance Desimini

c. Chapter 25: Peter Bartlett

2. Use your ICD-10-CM and CPT code books to identify all appropriate diagnosis, procedure, and E/M codes for each case. Record your answers in the provided Code-A-Note Review Notes template.

3. Now use the Code-A-Note feature in Find-A-Code to determine its level of accuracy.

a. Notice that each case has been reproduced at the end of this document. This is to make it easier for you to copy the documentation into the Code-A-Note.

b. Record your findings for each case in the provided Code-A-Note Review Notes template.

c. Please see the How to Use Code-A-Note document in Blackboard if you need additional directions on how to use Code-A-Note.

4. If the codes provided by Code-A-Note are different than the codes you identified using the code books, then provide rationale to support your code choice(s). Record these explanations in the provided Code-A-Note Review Notes template.

5. In the same Word document, provide a three-five paragraph (300-750 words) written recommendation of whether or not Find-A-Code should be purchased. The written recommendation should include the following parts:

a. A summary of the results of your encoder review: How accurate was Code-A-Note? Include specific details that reference the codes from the patient cases.

b. Notes on the ease of use of Code-A-Note. How easy or difficult will this be to implement in your office? How easy or difficult will it be to train coders on the use of Code-A-Note?

c. Your final recommendation: Should Find-A-Code be purchased, and why?

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

7. Submit your work by the designated due date.

MCCG240 Evaluation and Management Services

Computer Assisted Coding Audit

Rubric

Level 3	Level 2	Level 1	Level 0
		50-42.5	42.49-35	34.9-32.5	32.49-0
Accuracy of code assignments	Student correctly assigned 85-100% (14-16) of the correct codes in all 3 cases	Student correctly assigned 70-84% (12-13) of the correct codes in all 3 cases	Student correctly assigned 65-69% (11) of the correct codes in all 3 cases	Student correctly assigned 64% (10) or less of the correct codes in all 3 cases

 

45-38.25	38.24-31.5	31.49-29.25	29.24-0
Recommendation	Student provides a written recommendation about the purchase of Find-A-Code, which includes correct and thorough explanations with numerous, specific details to the patient cases. Written recommendation meets or exceeds the minimum length requirement (3-6 paragraphs or 300-900 words).	Student provides a written recommendation about the purchase of Find-A-Code, which includes mostly correct and somewhat thorough explanations with some details to the patient cases. Written recommendation is at least two-thirds of the minimum length requirement (2 paragraphs or 200 words).	Student provides a written recommendation about the purchase of Find-A-Code, which includes somewhat correct explanations with few details to the patient cases. Written recommendation is at least one-third of the minimum length requirement (1 paragraph or 100 words).	Student provides a written recommendation about the purchase of Find-A-Code, which includes mostly incorrect explanations with no details to the patient cases. Written recommendation less than one-third of the minimum length requirement (less than 1 paragraph or 100 words). Or student did not provide a written recommendation.
5-4.5	4.49-3.5	3.49-3.25	3.24-0
Institutional Outcome	Quantitative & Scientific Reasoning:  Work indicates that the student has exceeded expectations for this institutional outcome.	Quantitative & Scientific Reasoning:  Work indicates that the student has successfully met expectations for this institutional outcome.	Quantitative & Scientific Reasoning:  Work indicates that the student has partially met expectations for this institutional outcome.	Quantitative & Scientific Reasoning:  Work indicates that the student has not or scarcely met expectations for this institutional outcome.
Final Score:	Comments:

Patient Cases

Chapter 24: Olivia Fernandez

WASSERMAN UROLOGY CENTER

233 STREAMLINE DRIVE • MAZE, FL 32811 • 407-555-6591

PATIENT:

FERNANDEZ, OLIVIA

ACCOUNT/EHR #:

FERNOL001

DATE:

07/16/18

Attending

Physician:

Laverne Aspiras, MD

CLINICAL HISTORY: This patient, a 5-year-old Hispanic female who had been previously healthy, was admitted to the hospital 5 days ago with bloody diarrhea and dehydration. She was treated with bowel rest and intravenous fluids. Her diarrhea seemed to be improving; however, this morning she experienced a prolonged generalized convulsion and she was transferred emergently.

Upon arrival to the PICU, she appeared quite ill. She was extremely irritable and quite pale. A blood coagulation test is performed.

IMPRESSION: Hemolytic uremic syndrome caused by E. coli H:0157.

PLAN: Dialysis is ordered.

Laverne Aspiras, MD

LA/pw D: 07/16/18 09:50:16  T: 07/18/18 12:55:01

Chapter 24: Lance Desimini

WASSERMAN UROLOGY CENTER
233 STREAMLINE DRIVE • MAZE, FL 32811 • 407-555-6591

PATIENT:

DESIMINI, LANCE

ACCOUNT/EHR #:

DESILA001

DATE:

12/03/18

Physician:

Sunil Kaladuwa, MD

This is a 7-year-old male who presents to the office with his mother with a chief complaint of bedwetting twice a week. Essentially he is healthy except for an occasional cough and fever that the mother attributes to exposure to other children with colds. Urinary discharge occurs at night only, and he therefore has to wear diapers to bed. His mother is worried since his brothers and sisters were all toilet trained by this age. There is no history of dysuria, intermittent daytime wetness, polyuria, or polydipsia.

PAST MEDICAL HISTORY: Unremarkable.

FAMILY HISTORY: Significant for his father being a bedwetter. His child development is normal.

EXAM: VS T 37, P 110, R 20, BP 107/64, Ht 102 cm (25th percentile), Wt 16.2 kg (25th percentile). He is alert and active, in no distress. His appearance is nontoxic. HEENT and neck exams are negative. His lungs are clear bilaterally. His heart has a normal rate and rhythm, normal S1 and S2, and no murmurs or rubs. No masses, organomegaly, or tenderness is appreciated on exam of his abdomen. Bowel sounds are present. He has no inguinal hernias. He has a circumcised penis of normal size. The meatus is normally placed, without discharge. No phimosis is present. His testes are descended bilaterally and are of normal size (Tanner stage 1). His back is straight with normal posture with no scoliosis or tenderness, or midline defects. His extremities and muscle tone are normal. His gait is normal. His speech and behavior are age-appropriate.

DX: Enuresis

PLAN: Mother is told that bladder control is usually attained between the ages of 1 and 5 years and bedwetting becomes less frequent with each passing year. I recommend that she be supportive of her son’s dry nights and avoid criticism of wet nights. I also recommend avoiding excessive fluid intake 2 hours before bedtime and emptying his bladder at bedtime.

Sunil Kaladuwa, MD

SK/mg D: 12/03/18 09:50:16  T: 12/06/18 12:55:01

Chapter 25: Peter Bartlett

ALTERNATIVE MEDICAL SERVICES

517 DIVERGENT WAY • HARRIS, FL 32811 • 407-555-9999

PATIENT:

ACCOUNT/EHR #:

DATE:

BARTLETT, PETER

BARTPE001

10/07/18

This patient is a 45-year-old male complaining of neck pain and lower back pain that have become increasingly more difficult since an MVA 2 weeks ago.

Patient states he was driving down Main Street and was struck from behind by another driver. He states that the pain has been constant since about 2 hours after the accident. He describes the pain as pressure, “pulling, aching” in his neck and constant aching in his lower back. The sharpness of the pain increases with movement and subsides when he lies still. It is painful to bend or walk. He said that he went to see his family physician, Dr. Farina, last week, who referred him to our office.

X-rays: X-rays performed in office today: Cervical x-rays (PA-Lat) show multiple subluxations of the cervical vertebrae with pain on movement. Dens and spinous process are intact. No breaks or fracture noted. Lumbar spine x-rays (PA-Lat) is intact with no breaks or fractures.

TREATMENT PLAN: Spinal manipulations at neck and lower back 2–3×  per week for approximately 3 months, followed by moist heat to release spasm and pain and increase circulation. This will be followed by cryotherapy for the reduction of swelling and pain. Ice/heat: prn.

PROGNOSIS: Good with no permanent impairment expected.

DIAGNOSIS: Cervical hyperflexion; subluxations of cervical vertebrae C2-C5; lumbar sprain/strain, after two-car MVA. Therapeutic treatments provided during this visit: Chiropractic adjustment three to four regions; traction; hot/cold pack therapy.

Natalie Crystalis, DC

NC/ml  D: 10/07/18 11:47:39  T: 10/08/18 09:55:36

Find-A-Note

How to Use Code-A-Note

1. Access Find-A-Code from the AHIMA vLab.

2. Select the green Code-A-Note icon from the list of options.

.

3. Now you are in the Code-A-Note Screen. Fill out the Patient information and enter your documentation into the Notes/EMR in the box on the left.

4.

Select Scan Notes at the bottom of the screen.

5. Select the coding system tabs at the top right of the screen to check the codes and ensure they are applicable to the documentation. Make sure to select all tabs to check the codes for each coding system.