Electronic Health Records
Plagiarism Check Citation &References should be mentioned in APA 7th Edition#5 Answer the following questions for the lab, making sure to answer these DIRECTLY in the space provided. Do not alter the Word document in any way. If this is not followed, there is an automatic mark of zero given. Use the PowerPoint slides and conduct any internet searches if required. Remember that a great paper will go above and beyond what I am asking with extra examples and references added. Any external references, including the e-book or slides, must be cited using APA as a guide. Don’t forget to include in-text citations that show me specifically where your reference was used to provide background to your answer(s). Use a separate page at the end of the lab, labeled “References”, to list your references. If APA is not properly used, marks will be deducted. Use default paragraph settings and format, and there will much more focus on ensuring that your spelling and grammar are up to par. Part 1 ( 30 points) – 500 to 750 words List and specifically explain three advantages that computer-assisted coding has over an actual employee whose only role is to code, along with a practical healthcare-related example that demonstrates that example in action. Each one should have a separate title, and the explanation and example should be in separate paragraphs. Part 2 (10 points) – 250 words How would you pull information together using a diagnostic code or two as a filter to answer a healthcare-related question? Please provide a healthcare-related practical example that would demonstrate this.
Part 3 (10 points) – 250 words When considering your application to come to Fanshawe College, you had to use both primary and secondary sources of data. In a table, list what these sources of data were and how they helped you make the decision to come to Fanshawe College. INFO-6060 – Electronic Health Records
Lab #5
Answer the following questions for the lab, making sure to answer these DIRECTLY in the space provided.
Do not alter the Word document in any way. If this is not followed, there is an automatic mark of zero
given.
Use the PowerPoint slides and conduct any internet searches if required. Remember that a great paper will
go above and beyond what I am asking with extra examples and references added.
Any external references, including the e-book or slides, must be cited using APA as a guide. Don’t forget to
include in-text citations that show me specifically where your reference was used to provide background to
your answer(s). Use a separate page at the end of the lab, labeled “References”, to list your references. If
APA is not properly used, marks will be deducted.
Use default paragraph settings and format, and there will much more focus on ensuring that your spelling
and grammar are up to par.
Part 1 ( 30 points)
List and specifically explain three advantages that computer-assisted coding has over an actual
employee whose only role is to code, along with a practical healthcare-related example that
demonstrates that example in action. Each one should have a separate title, and the explanation
and example should be in separate paragraphs.
Part 2 (10 points)
How would you pull information together using a diagnostic code or two as a filter to answer a
healthcare-related question? Please provide a healthcare-related practical example that would
demonstrate this.
Part 3 (10 points)
When considering your application to come to Fanshawe College, you had to use both primary and
secondary sources of data. In a table, list what these sources of data were and how they helped you make
the decision to come to Fanshawe College.
Chapter 9
Diagnostic and Procedural Coding
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Learning Objectives
9.1
9.2
9.3
9.4
Define nomenclature and identify its role in the electronic
health record (EHR).
Define classification systems and identify specific
classification systems used for coding for each healthcare
delivery system.
Discuss the purposes of diagnostic and procedural coding.
Discuss the classification systems used to code diagnoses
and procedures, including the International Classification
of Diseases, Current Procedural Terminology, Healthcare
Common Procedure Coding System, Current Dental
Terminology, and the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition.
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Learning Objectives, Continued
9.5 Discuss how EHRs affect coding processes.
9.6 Define and describe computer-assisted coding.
9.7 Define and discuss important coding concepts, such as
concurrent coding and present on admission.
9.8 Discuss external and internal coding auditing.
9.9 Demonstrate coding processes utilizing EHR software.
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Introduction
• Clinical coders assign and validate diagnostic and procedural
codes to represent:
– The patient’s diseases or conditions
– The treatment rendered
• Codes are used for:
– Reimbursement
– Research
– Decision making
– Public health reporting
– Quality improvement
– Resource utilization
– Healthcare policy and payment
• Coding is facilitated by EHRs.
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9.1 Nomenclature Systems
• Nomenclature: a common system of naming things
• In EHRs, nomenclature is a system of common clinical and
medical terms, with codes to represent diseases,
procedures, symptoms, and medications.
• The term nomenclature is used interchangeably with
terminology.
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9.1 Nomenclature Systems, Continued
• Two common EHR nomenclature systems:
– SNOMED CT
• A standardized vocabulary of clinical terminology used by
healthcare providers for clinical documentation and reporting
• The world’s most comprehensive healthcare terminology
• Federally sanctioned
– MEDCIN
• Primarily used in physicians’ offices
• Derived from Centers for Medicare and Medicaid Services
(CMS) guidelines for evaluation and management coding
• Mapped to Current Procedural Terminology codes
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9.2 Classification Systems
• Classification system: a standardized coding method that
organizes diagnoses and procedures into related groups to
facilitate reimbursement, reporting, and clinical research
• Most widely used classification systems:
– International Classification of Diseases (ICD)
– Current Procedural Terminology (CPT)
• Both used by hospitals, medical offices, long-term care
facilities, ambulatory care centers, and many other
healthcare institutions
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9.2 Classification Systems, Continued
• Other classification systems include:
– Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5)
• Used to classify psychiatric disorders
– Healthcare Common Procedure Coding System (HCPCS)
• Used to code ancillary services and procedures
– Current Dental Terminology (CDT)
• Used to code dental procedures
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9.2 Classification Systems, Continued
• The Health Insurance Portability and Accountability Act of
1996 (HIPAA) stipulates code usage:
– ICD: diagnosis coding in all settings and hospital inpatient
procedure coding
– CPT: physician services and procedures
– CDT: dental claims
– HCPCS: ancillary services and procedures
– National Drug Codes: drugs
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9.2 Classification Systems, Continued
• Use of standardized classification systems directly impacts
health care, because the data is used for the following purposes:
Use of Coded Data
Explanation of Data Use
Reimbursement
Enables providers/facilities to bill for services rendered to
patients
Research
Helps researchers with studies and clinical trials
Decision making
Informs operational and strategic planning in organizations
Public health
Assists public health agencies to monitor contagious diseases
and health risks
Quality improvement
Aids providers with clinical, safety, financial, and operational
quality improvement activities
Resource utilization
Allows for tracking and monitoring of resources used
Healthcare policy and
payment
Assists government and private agencies in establishing or
updating policy initiatives and payment methods
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9.2 Classification Systems, Continued
ICD
• History traceable to 18th-century England
– A rudimentary classification system was developed to study
high infant mortality rates.
– William Farr, one of the first medical statisticians, used the
system to categorize diseases by anatomic site and to monitor
mortality rates.
• 1891: Chicago’s International Statistical Institute
commissioned Jacques Bertillon to create a classification
system based on Farr’s work
– Known as the International List of Causes of Death
– Used by 26 countries
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9.2 Classification Systems, Continued
• 1948: the World Health Organization (WHO) endorsed the
6th revision of the International List of Causes of Death and
renamed it the Manual of the International Statistical
Classification of Diseases, Injuries, and Causes of Death
• Beginning of a new era in international vital and health
statistics
• 1955: 7th revision renamed the International Classification
of Diseases
• 8th and 9th revisions published in 1965 and 1975
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9.2 Classification Systems, Continued
• 1977: US government worked to establish a clinical
modification of ICD-9
• Goal: make it more applicable to diseases experienced by
US patients and provide detail sought by clinicians and
researchers
• US version: ICD-9, Clinical Modification (ICD-9-CM)
• Annual updates
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9.2 Classification Systems, Continued
• 1990: ICD-10 adopted by the World Health Assembly
• ICD-10 vs. ICD-9
– 68,000 codes in ICD-10; 13,000 in ICD-9
– All ICD-10 codes are alphanumeric; ICD-9 codes are mostly
numeric.
• 2015: US adopted:
– A version of ICD-10, the International Classification of
Diseases, Tenth Revision, Clinical Medication (ICD-10-CM)
– The International Classification of Diseases, Tenth Revision,
Procedural Coding System (ICD-10-PCS)
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9.2 Classification Systems, Continued
• ICD-11 has been developed and approved by the WHO.
– An alphanumeric classification system used only to code
diagnoses
– The first version of the ICD classification system designed for
use in EHR systems
– 55,000 diagnosis codes (14,400 in ICD-10)
• US implementation likely between 2025–2030
• ICD-10-PCS will remain in use in the United States with
code updates occurring annually.
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9.2 Classification Systems, Continued
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9.2 Classification Systems, Continued
CPT Coding
• The classification system that describes medical, surgical,
and diagnostic services
• Used to report the procedures and services rendered to
patients
• Published by the American Medical Association and
updated every January
• Includes more than 8,000 codes
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9.2 Classification Systems, Continued
Healthcare Common Procedure Coding System (HCPCS)
• CPT codes are part of the HCPCS.
• HCPCS is divided into Levels I and II.
• Level I: CPT codes
• Level II: National Codes
– Used to bill for for products, services, and supplies not
included in the CPT codes, e.g.:
• Ambulance services
• Durable medical equipment
• Prosthetics
• Orthotics
• Published by CMS
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9.2 Classification Systems, Continued
Current Dental Terminology
Coding (CDT)
• Code set on dental procedures
and nomenclatures
• Published and annually updated
by the American Dental
Association
• Used to report all dental
services, except for some oral
surgery procedures
• Dentists use ICD to report
diagnoses and CDT to report
services and procedures.
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9.2 Classification Systems, Continued
DSM-5
• Published by the American Psychiatric Association
• Contains codes for every known behavioral health
condition
• Used as a supportive diagnostic tool
• Providers may not submit bills with DSM codes because
DSM is not a HIPAA-approved code set for electronic
transactions.
• Crosswalking: translating a code in one code set to a code
in another set
• DSM codes are crosswalked to ICD codes.
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9.3 Code Assignment
• Coders have traditionally used printed coding manuals, but
with high volumes of health records to code, this is
cumbersome.
• Clinical encoder: a software program that helps coding
professionals navigate coding pathways with the end result
of assigning codes
• Coders must understand how to assign codes using both
encoder software and printed coding manuals.
– Certification exam
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9.3 Code Assignment, Continued
• Diagnosis-related group (DRG): a patient classification
system that groups hospital inpatients of similar age, sex,
diagnoses, and treatments
• Each DRG is associated with a dollar amount for which the
facility expects to be reimbursed.
• Inpatient prospective payment system (IPPS): the first
DRG system; implemented in 1983 to reimburse acute care
hospitals for the treatment of Medicare patients
• Purpose of a DRG system: to relatively equalize payments to
hospitals for care provided to similar patients with the
same clinical characteristics
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Consider This
Patient A: final principal diagnosis: acute respiratory failure; principal procedure:
mechanical ventilation, more than 96 hours
Patient B: final principal diagnosis: acute myocardial infarction; principal
procedure: coronary artery bypass
Analyze the table above. Why do reimbursement rates for Patients A and B vary
among hospitals in the time before the Medicare DRG implementation? Why are
the reimbursement rates the same for Patients A and B among the hospitals under
the Medicare DRG system? Under the Medicare DRG system, why is the
reimbursement for Patient A not the same as Patient B?
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Consider This
Through the Medicare inpatient prospective payment system
(IPPS), the US government spends more than $130 billion
every year in payments to acute care hospitals for inpatient
care. Because the IPPS depends on diagnostic and procedural
coding to calculate the payments to acute care hospitals, what
would happen if coding staff incorrectly coded charts 10% of
the time?
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9.4 Coding and the Electronic Health
Record
• Healthcare facilities initiate the billing process after each
visit or admission.
• Medical coder: codes diagnoses and procedures in
preparation for billing claims
• Medical coding: the process of assigning and validating
standardized alphanumeric identifiers to the diagnoses
and procedures documented in a health record
– Diagnosis: a statement or conclusion that describes a
patient’s illness, disease, or health problem
– Procedure: an activity performed on an individual to
improve health, treat disease or injury, or identify a diagnosis
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9.4 Coding and the Electronic Health
Record, Continued
• Coded data is used:
– By healthcare providers to seek reimbursement from the
government, private insurance companies, and other thirdparty payers
• Third-party payer: an entity other than the patient that is
financially responsible for payment of the medical bill
• Self-pay patients: pay for the entire visit themselves
– In public health management to monitor disease and death
rates
• Morbidity: the rates of diseases in a population
• Mortality: the rate of death in a population
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9.4 Coding and the Electronic Health
Record, Continued
• The health record
is the starting point
for reporting
medical codes.
• Operative report:
a form of clinical
documentation that
contains the details
of a particular
surgery or
procedure
performed on a
patient
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9.4 Coding and the Electronic Health
Record, Continued
• Steps in reporting codes from an operative report:
1. Read the report and verify that the diagnoses and
procedures listed at the top of the report are supported by
the documentation of the procedure provided in the body of
the report.
2. Identify the correct codes for the diagnoses and procedures
using resources such as coding manuals and coding
software.
3. Enter the medical codes into the EHR to prepare the account
for billing.
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9.4 Coding and the Electronic Health
Record, Continued
• Discharged not final billed (DNFB): patient accounts not able
to be final billed to the insurance company or responsible party
because of a lack of final coding, insurance verification, or other
data errors
– Flagged and included on a data report by the EHR system
• EHR work-list reports present patient accounts for coding in a
priority order.
• EHRs can perform concurrent coding: the task of coding while
a patient is still receiving treatment in a hospital.
– Accelerates the final coding process
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9.4 Coding and the Electronic Health
Record, Continued
• Coders:
– Navigate through the EHR
while also using clinical
encoder software
– Read and enter patient
diagnoses/procedures into
the encoder
• Physician query: a request,
typically from a coder or a
case manager, to add
documentation to the health
record that clarifies a
diagnosis or procedure
performed
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9.4 Coding and the Electronic Health
Record, Continued
• Accurate code assignments result in appropriate
reimbursement.
• Upcoding: documenting for the purpose of claiming a
higher-paying DRG and, therefore, increased
reimbursement
– Illegal
– Unintentional upcoding is considered abuse.
– Intentional upcoding is considered fraud.
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9.4 Coding and the Electronic Health
Record, Continued
• Computer-assisted coding (CAC) programs
automatically assign diagnosis and procedure codes based
on electronic documentation.
• When used, the coder must:
– Validate the codes
– Ensure that coding guidelines have been followed
– Validate whether the coded diagnoses were present on
admission (POA), meaning the patient had the diagnoses
when admitted to the facility
• Hospital-acquired diagnoses developed when the patient was
an inpatient in the hospital.
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9.5 Internal and External Auditing for
Coding Compliance
• External companies and organizations routinely audit
healthcare facilities to verify coding accuracy.
– Ensures that coders followed coding guidelines and
regulations
– Conducted by insurance companies, auditing companies
hired by insurance companies, Medicare and Medicaid
auditors
• Insurance audits: conducted for patient accounts that
contain codes that are historically problematic for coders,
resulting in a high error rate, or exceed a specific threshold
(e.g., $100,000)
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9.5 Internal and External Auditing for
Coding Compliance, Continued
• The Recovery Audit Contractor program identifies
improper payments made for healthcare services provided
to Medicare beneficiaries.
– Overpayment and underpayment due to inaccurate coding
• Any healthcare provider that bills Medicare Part A or B
may be audited under the program.
• Has resulted in the return of more than $10 billion to
Medicare
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9.5 Internal and External Auditing for
Coding Compliance, Continued
• Healthcare providers can reduce the risk of coding errors
by:
– Conducting internal coding audits
– Providing intensive coder training
– Reauditing the coding areas that were the subject of the
coder training
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