MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay)

MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay)

As part of your internship with South Padre Medical Center, you are working under the supervision of the coding supervisor, Marla Kauffman. The clinic’s CDI Director, George Bowman, wants to better educate the physicians on the importance of accurate and complete medical records.  Therefore, George is planning on beginning a series of education sessions every month. He has asked Marla to prepare a presentation on proper documentation.

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Marla thinks that helping with this presentation would be a wonderful opportunity for you during your internship so that you can learn how to improve clinical documentation by identifying some key elements that are missing or unclear inpatient documentation. Marla’s plan for the presentation is to present some cases and examples where the coders did not have the information they needed to code. MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay). Marla has asked you to assist in preparing for this presentation by identifying any missing or unclear information from four patient records and drafting a PowerPoint presentation on your findings.

Because you are a new coder, Marla also thinks it would be helpful for you to research the importance of proper documentation and ways to ensure documentation is complete and accurate and then include information from your research findings into your PowerPoint presentation.

MCCG262 Professional Coder Practicum

Documentation Presentation

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

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

• Course outcome: Demonstrate competency and proficiency required for billing and coding operations in outpatient services.
• Course outcome: Evaluate patient records for accuracy and completeness, as defined by policy, regulations, and standards, and summarize finding to share with different stakeholders in the coding process. MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay).

• Program outcome: Evaluate the accuracy and completeness of the patient record as defined by policy, external regulations, and standards.
• Institutional outcome – Information Literacy and Communication: Utilize appropriate current technology and resources to locate and evaluate information needed to accomplish a goal, and then communicate findings in visual, written, and/or oral formats.

Relevant Background Information:

Evaluating documentation for accuracy and completeness is part of a coding professional’s daily duties.  It is essential that coders understand what components make up a complete and accurate medical record.  As coders are reading through patients’ medical records to code them, they determine if the documentation is not complete or needs more clarity.  In those instances, the coder will obtain the missing documentation or query the physician for further clarification. MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay).

Assignment Purpose:

This assignment asks you to review documentation in real patient medical records and specify if there is any missing or unclear documentation that the coder would need in order to assign the correct codes.

Assignment Directions:

As part of your internship with South Padre Medical Center, you are working under the supervision of the coding supervisor, Marla Kauffman.  The clinic’s CDI Director, George Bowman, wants to better educate the physicians on the importance of accurate and complete medical records.  Therefore, George is planning on beginning a series of education sessions every month.  He has asked Marla to prepare a presentation on proper documentation.

Marla thinks that helping with this presentation would be a wonderful opportunity for you during your internship so that you can learn how to improve clinical documentation by identifying some key elements that are missing or unclear inpatient documentation.  Marla’s plan for the presentation is to present some cases and examples where the coders did not have the information they needed to code.  Marla has asked you to assist in preparing for this presentation by identifying any missing or unclear information from four patient records and drafting a PowerPoint presentation on your findings. MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay).

Because you are a new coder, Marla also thinks it would be helpful for you to research the importance of proper documentation and ways to ensure documentation is complete and accurate and then include information from your research findings into your PowerPoint presentation.

Once you have reviewed the four patients’ medical records and completed your research, you will present your PowerPoint to Marla so she can determine how she wants to incorporate it into her presentation at the education session for the physicians MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay).

Follow the steps below to complete this assignment:

Part 1: Research

Conduct research to find information on the importance of proper documentation and ways to ensure documentation is complete and accurate.

1. Make sure you find enough information to effectively explain proper documentation in your PowerPoint presentation.
2. Make sure your sources are authoritative and recent.

Part 2: Patient Record Review

2. Locate the following patient records in the AHIMA vLab Outpatient Clinic Cases:
   1. 410057
   2. 410092
   3. 410198
   4. 410296
3. Your coding supervisor has also provided you with a coding summary for each patient record. You may find these in the coding summary at the end of this document.
4. Review the patient records. For each patient record, identify if there is any missing or unclear information the coder would need. MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay).

Part 3: The PowerPoint Presentation

5. Gather the information from your sources and from your review of the four identified patient records. Create a PowerPoint presentation that achieves the following:
   1. Provides examples from all four patient records of pieces of the medical records that are properly documented.
   2. Provides examples from all four patient records of pieces of the medical records that do not have accurate or complete information.
   3. Explains the importance of proper medical documentation.
   4. Provides suggestions to ensure physician documentation is complete and accurate.
   5. Is the right length to thoroughly cover all necessary information MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay).

MCCG262 Professional Coder Practicum

Documentation Presentation

Rubric

	Level 3	Level 2	Level 1	Level 0
	50-42.5	42.4-35	34.9-32.5	34.2-0
Content	Student includes accurate, thorough, and detailed explanations of all presentation requirements.	Student includes accurate, somewhat thorough, and somewhat detailed explanations of most (75%)of the presentation requirements.	Student includes accurate explanations with little to no details of half of the presentation requirements.	Student includes inaccurate explanationswithout details of less than half of the presentation requirements.
	35-29.75	29.74-24.5	24.4-22.75	22.74-0
Presentation	Presentation length is adequate for the material being presented.Audio commentary matches slides presented.	Presentation length is mostly adequate for the material being presented, but the presentation would have better if the length was slightly adjusted.Audio commentary matches slides presented.	Presentation length is partially adequate for the material being presented, but the presentation would have better if the length was significantly adjusted.Audio commentary does not match slides presented.	Presentation length is inadequate for the material being presented.Audio commentary does not match slides presented.
	10-8.5	8.4-7	6.9-6.5	6.4-0
Sources	Student refers to authentic and recent sources that provide abundant information for the material being presented.Student includes the sources for all information in the PowerPoint.	Student refers to authentic and recent sources that provide adequate information for the material being presented.Student includes the sources for most (at least 75% of the) information in the PowerPoint.	Student refers to authentic and recent sources that provide inadequate information for the material being presented.Or the sources are not authentic or recent.Student includes the sources for half of the information in the PowerPoint.	Student fails to refer any sources.Student fails to include the sources or only includes sources for less than half of the information in the PowerPoint.
	5-4.25	4.24-3.50	3.49-3.25	3.24-0
Institutional Outcome	Information Literacy and Communication:Work indicates that the student has exceeded expectations for this institutional outcome.	Information Literacy and Communication:Work indicates that the student has successfully met expectations for this institutional outcome.	Information Literacy and Communication:Work indicates that the student has partially met expectations for this institutional outcome.	Information Literacy and Communication:Work indicates that the student has not or scarcely met expectations for this institutional outcome.
	Final ScorMCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay)e:	Comments:

MCCG262 Professional Coder Practicum

Documentation Presentation

Coding Summary

The coding supervisor has provided you with the coding summary of each coded case and these are as follows:

410057

Diagnosis Codes:

• Dx Reason for Visit: C50.411 Malignant neoplasm of upper outer quadrant of right female breast
• Primary Diagnosis: C50.411 Malignant neoplasm of upper outer quadrant of right female breast
• Secondary Diagnosis: Z17.1 Estrogen receptor negative status [ER-] MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay)

Detailed CPT Procedures:

• 19301-RT Partial Mastectomy; (RT Right side of body)
• 14301 Adjnt tis trnsfr/reargmt any area 30.160 sq cm
• 19285-RT Placement of breast localization device(s), percutaneous; first lesion, including ultrasound guidance; (RT – Right side of the body) MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay)

410092

Diagnosis Codes:

• Primary Diagnosis: D12.2 Benign neoplasm of ascending colon
• Secondary Diagnoses:
  • I10 Essential (primary) hypertension
  • 9 Type 2 diabetes mellitus without complications
  • 909 Unspecified asthma, uncomplicated
  • 9 Hypothyroidism, unspecified
  • 9 Gastro-esophageal reflux disease without esophagitis
  • 0 Pure hypercholesterolemia

Coder’s note: There are numerous laboratory procedures on this record relating to gene analysis.  Per clinic policies, we are not assigning codes to these as they would most probably be captured by the chargemaster system in place at the facility. Procedure code could not be assigned.

410198:

Diagnosis Codes:

• Dx Reason for Visit: L72.0 Epidermal cyst
• Primary Diagnosis: L72.0 Epidermal cyst
• Secondary Diagnoses: E03.9 Hypothyroidism, unspecified

Detailed CPT Procedures:

• 11441 Excision, other benign lesion including margins, except skin tag, face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm
• 12051 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay).

410296:

Diagnosis Codes:

• Dx Reason for Visit: Z01.21 Encounter for dental examination and cleaning with abnormal findings
• Primary Diagnosis: Z01.21 Encounter for dental examination and cleaning with abnormal findings
• Secondary Diagnoses:
  • F79 Unspecified intellectual disabilities
  • 0 Autistic disorder
  • 409 Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus
  • 5 Hyperlipidemia, unspecified
  • 7 Periapical abscess without sinus

Detailed HCPCS Codes:

• D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
• D2332 Resin based composite three surfaces, anterior
• D2393 Resin based composite three surfaces, posterior
• D2140 Amalgam one surface, primary or permanent
• D0180 Comprehensive periodontal evaluation new or established patient
• MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding Essay)