Medical Coding

HIM215FinalProjectGuidelinesandRubric.docx

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HIM 215 Final Project Guidelines and Rubric

Overview

Medical coding is one of the main engines driving the healthcare system. While not visible to all stakeholders, medical coders are essential. Without them, the healthcare industry would be unable to efficiently share important information, which could result in healthcare providers not receiving payment for their services. More specifically, a medical coder translates the records of patient visits into numeric and alphanumeric code. This coding process is essential to ensuring that accurate bills and claims are established.

In this assignment, you will be tasked with reviewing a patient record and applying the appropriate coding to the different sections. While coding the patient record, you will work with ICD-10, HCPCS II, and CPT classification systems to accurately code diagnoses and procedures. Along with the coded patient record, you will also provide a rationale that communicates how you arrived at your decisions for particular codes.

The project is divided into three milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. The milestones for this course will help you practice the elements of the final project. These milestones will be submitted in Modules Three, Four, and Five. The final product will be submitted in Module Seven.

In this assignment, you will demonstrate your mastery of the following course outcomes:

· Identify the main terms within a patient health record for determining valid coding

· Differentiate between different coding classification systems for ensuring effective recording of patient health information

· Explain the process and results of validating correct code through the effective use of electronic healthcare resources

· Apply appropriate healthcare guidelines in making determinations of coding assignments

Prompt

For this project, you will review a patient record and apply the appropriate diagnosis and procedure coding. You will also provide a rationale that communicates how you arrived at your decision for a particular code.

Note: The patient record you will use for the final project is not the same record you will use for the milestones.

Specifically, the following critical elements must be addressed:

I. ICD-10: In this section, you will review the patient medical record and apply the appropriate ICD-10 coding to the diagnosis. You will also be asked to provide your rationale for how you arrived at a particular code.

A. Review the chart notes and determine a diagnosis. Explain how you arrived at your determination.

B. Determine the primary and secondary diagnosis. Describe what led you to this determination.

C. Identify the main term(s) for each diagnosis and provide a rationale to support your response.

D. Use an encoder and search for the main term of the diagnosis. Describe the results of the search and the process applied to effectively use the encoder. Note: You will use SelectCoder as your encoder for this task.

E. Describe how you narrowed down your diagnosis selection based on descriptions and adjectives while using the encoder. Provide the narroweddown list to support your response.

F. Assign the diagnosis code to the record and explain why this code is the most appropriate for this diagnosis.

II. HCPCS II: In this section, you will review the patient medical record and apply the appropriate HCPCS II coding to the procedure(s). You will also be asked to provide your rationale for how you arrived at a particular code.

A. Review the chart notes and determine the HCPCS II procedure. Explain how you arrived at your determination.

B. Identify the main term(s) for each HCPCS II procedure and provide a rationale to support your identification.

C. Use an encoder and search for the main term of the HCPCS II procedure. Describe the results of the search and the process applied to effectively use the encoder. Note: You will use SelectCoder as your encoder for this task.

D. Describe how you narrowed down your HCPCS II procedure selection based on descriptions and adjectives while using the encoder. Provide the narrowed-down list to support your response.

E. Assign the HCPCS II procedure code to the record and explain why this code is the most appropriate for this procedure.

III. CPT: In this section, you will review the patient medical record and apply the appropriate CPT coding to the procedure(s). You will also be asked to provide your rationale for how you arrived at a particular code.

A. Review the chart notes and determine a CPT procedure. Explain how you arrived at your determination.

B. Identify the main term(s) for each CPT procedure and provide a rationale to support your identification.

C. Use an encoder and search for the main term of the CPT procedure. Describe the results of the search and the process applied to effectively use the encoder.

D. Describe how you narrowed down your CPT procedure selection based on descriptions and adjectives while using the encoder. Provide the narrowed-down list to support your response.

E. Assign the CPT procedure code to the record and explain why this code is the most appropriate for this procedure.

Milestones

Milestone One: ICD-10 Coding

In Module Three, you will practice coding ICD-10. You will identify the ICD-10 diagnosis, determine which diagnosis is primary and which is secondary, identify the main terms, and use SelectCoder to code in ICD-10. This is a good time to iron out any specific issues you are having and contact the instructor with questions. This milestone will be graded with the Milestone One Rubric.

Milestone Two: HCPCS II Coding

In Module Four, you will practice coding HCPCS II. You will identify the proper procedures and main terms for each procedure, and code HCPCS II. This is a good time to iron out any specific issues you are having and contact the instructor with questions. This milestone will be graded with the Milestone Two Rubric.

Milestone Three: CPT and E/M Coding

In Module Five, you will practice coding CPT and E/M. You will identify the proper procedures and main terms for each procedure, and code CPT and E/M. This is a good time to iron out any specific issues you are having and contact the instructor with questions. This milestone will be graded with the Milestone Three Rubric.

Final Submission: Coded Patient Record with Rationale

In Module Seven, you will submit your final project. It should be a complete, polished artifact containing all of the critical elements of the final product. It should reflect the incorporation of feedback gained throughout the course. This submission will be graded with the Final Project Rubric.

Deliverables

Milestone	Deliverable	Module Due	Grading
One	ICD-10 Coding	Three	Graded separately; Milestone One Rubric
Two	HCPCS II Coding	Four	Graded separately; Milestone Two Rubric
Three	CPT and E/M Coding	Five	Graded separately; Milestone Three Rubric
	Final Submission: Coded Patient Record with Rationale	Seven	Graded separately; Final Project Rubric

Final Project Rubric

Guidelines for Submission: Your coded patient record with rationale should be a 1- to 2-page Microsoft Word document, double spaced, with 12-pt. Times New Roman Font, one-inch margins, and APA formatting.

Critical Elements

Exemplary (100%)

Proficient (85%)

Needs Improvement (55%)

Not Evident (0%)

Value

ICD-10: Diagnosis

Meets “Proficient” criteria, and explanation demonstrates keen insight into making diagnosis determinations

Determines a diagnosis, explaining how the diagnosis was determined

Determines a diagnosis and explains how the diagnosis was determined, but explanation is cursory or lacks detail

Does not determine a diagnosis

5.94

ICD-10: Primary and

Secondary

Meets “Proficient” criteria, and description demonstrates keen insight into classifying diagnoses as primary or secondary

Determines the primary and secondary diagnosis and describes what led to this

determination

Determines the primary and secondary diagnosis and describes what led to this determination, but description is cursory or lacks detail

Does not determine the primary and secondary diagnosis

5.94

ICD-10: Main Term(s)	Meets “Proficient” criteria, and rationale demonstrates a complex grasp on identifying main terms	Identifies the main term(s) for each diagnosis and provides rationale to support response	Identifies the main term(s) for each diagnosis and provides rationale to support response, but rationale is cursory or illogical	Does not identify the main term(s) for each diagnosis	7.92
ICD-10: Encoder	Meets “Proficient” criteria, and description demonstrates a sophisticated awareness of how to use an encoder effectively	Describes the results of the search and the process applied to effectively use the encoder	Describes the results of the search and the process applied to effectively use the encoder, but description is cursory or lacks detail, or some results are inaccurate	Does not describe the results of the search	3.96
ICD-10: Diagnosis Selection	Meets “Proficient” criteria, and description offers keen insight into narrowing diagnosis options when using an encoder	Describes how the diagnosis selection was narrowed down based on descriptions and adjectives while using the encoder, and provides the narrowed-down list to support response	Describes how the diagnosis selection was narrowed down based on descriptions and adjectives while using the encoder, and provides the narrowed-down list, but description is cursory or inaccurate, or provided list does not support response	Does not describe how the diagnosis selection was narrowed down	3.96
ICD-10: Assign the Diagnosis Code	Meets “Proficient” criteria, and explanation demonstrates a complex grasp on assigning codes to records	Assigns the diagnosis code to the record, explaining why the code is most appropriate for the diagnosis	Assigns the diagnosis code to the record, explaining why the code is most appropriate for the diagnosis, but explanation is cursory or illogical	Does not assign the diagnosis code to the record	7.92
HCPCS II: HCPCS II Procedure	Meets “Proficient” criteria, and explanation demonstrates keen insight into making HCPCS II procedure determinations	Determines a HCPCS II procedure, explaining how the HCPCS II procedure was determined	Determines a HCPCS II procedure and explains how the HCPCS II procedure was determined, but explanation is cursory or lacks detail	Does not determine a HCPCS II procedure	5.94
HCPCS II: Main Term(s)	Meets “Proficient” criteria, and rationale demonstrates a complex grasp on identifying main terms	Identifies the main term(s) for each HCPCS II procedure and provides rationale to support response	Identifies the main term(s) for each HCPCS II procedure and provides rationale to support response, but rationale is cursory or illogical	Does not identify the main term(s) for each HCPCS II procedure	7.92

HCPCS II: Encoder	Meets “Proficient” criteria, and description demonstrates a sophisticated awareness of how to use an encoder effectively	Describes the results of the search and the process applied to effectively use the encoder	Describes the results of the search and the process applied to effectively use the encoder, but description is cursory or lacks detail, or some results are inaccurate	Does not describe the results of the search	3.96
HCPCS II: Procedure Selection	Meets “Proficient” criteria, and description offers keen insight into narrowing procedure options when using an encoder	Describes how the HCPCS II procedure selection was narrowed down based on descriptions and adjectives while using the encoder, and provides the narrowed-down list to support response	Describes how the HCPCS II procedure selection was narrowed down based on descriptions and adjectives while using the encoder, and provides the narrowed-down list, but description is cursory or inaccurate, or provided list does not support response	Does not describe how HCPCS II procedure selection was narrowed down	3.96
HCPCS II: Procedure Code	Meets “Proficient” criteria, and explanation demonstrates a complex grasp on assigning codes to records	Assigns the HCPCS II procedure code to the record, explaining why the code is most appropriate for the procedure	Assigns the HCPCS II procedure code to the record, explaining why the code is most appropriate for the procedure, but explanation is cursory or illogical	Does not assign the HCPCS II procedure code to the record	7.92
CPT: CPT Procedure	Meets “Proficient” criteria, and explanation demonstrates keen insight into making CPT procedure determinations	Determines a CPT procedure, explaining how the CPT procedure was determined	Determines a CPT procedure and explains how the CPT procedure was determined, but explanation is cursory or lacks detail	Does not determine a CPT procedure	5.94
CPT: Main Term(s)	Meets “Proficient” criteria, and rationale demonstrates a complex grasp on identifying main terms	Identifies the main term(s) for each CPT procedure and provides rationale to support response	Identifies the main term(s) for each CPT procedure and provides rationale to support response, but rationale is cursory or illogical	Does not identify the main term(s) for each CPT procedure	7.92
CPT: Encoder	Meets “Proficient” criteria, and description demonstrates a sophisticated awareness of how to use an encoder effectively	Describes the results of the search and the process applied to effectively use the encoder	Describes the results of the search and the process applied to effectively use the encoder, but description is cursory or lacks detail, or some results are inaccurate	Does not describe the results of the search	3.96
CPT: Procedure Selection	Meets “Proficient” criteria, and description offers keen insight into narrowing procedure options when using an encoder	Describes how the CPT procedure selection was narrowed down based on descriptions and adjectives while using the encoder, and provides the narrowed-down list to support response	Describes how the CPT procedure selection was narrowed down based on descriptions and adjectives while using the encoder, and provides the narrowed-down list, but description is cursory or inaccurate, or provided list does not support response	Does not describe how CPT procedure selection was narrowed down	3.96
CPT: Procedure Code	Meets “Proficient” criteria, and explanation demonstrates a complex grasp on assigning codes to records	Assigns the CPT procedure code to the record, explaining why the code is most appropriate for the procedure	Assigns the CPT procedure code to the record, explaining why the code is most appropriate for the procedure, but explanation is cursory or illogical	Does not assign the CPT procedure code to the record	7.92
Articulation of Response	Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-to-read format	Submission has no major errors related to citations, grammar, spelling, syntax, or organization	Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas	Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas	4.96
	Total	100%