HIM 360 Module Two Operative Note Activity Guidelines and Rubric

Overview: Review Chapter 1 in your textbook, Healthcare Code Sets, Clinical Terminologies, and Classifications Systems. It is important to understand the

purpose of ICD-10-PCS codes and how they are built. ICD-10-PCS codes are used within the inpatient hospital setting for procedure coding. As you review the

chapter, think about the seven different categories that are used to build the code. Once you have read about how to build a procedure code, you will then use

the ICD-10-PCS 2018 Tables and Index document to complete the following assignment.

When you are coding any type of surgical procedure, there are specific components required to meet The Joint Commission’s standards. For this assignment,

you will be auditing each operative note to make sure all components are included, and then you will code the procedure using ICD-10-PCS codes.

When you are reviewing operative notes for audit, there are several areas to examine. It is extremely important to verify that the documentation includes all the

elements required to make a complete chart. Operative notes should include at least these components:

Prompt: In Part 1 of this exercise, you will use the charts in the Module Two Operative Note Activity Template document to identify areas that have been

omitted from the patient operative notes. The first chart has been completed as an example. When you have completed the initial review of the chart, you will

then go to the CMS ICD-10-PCS Index and Table to access the ICD-10-PCS codes to assign the procedure code(s) to the chart.

In Part 2, you will write a short report that summarizes your findings. This should be written in the same document, under the “Report” heading.

Specifically, the following critical elements must be addressed:

Rubric