Professional Medical Coding: Essential Documentation and Case Examples

CODER PRESENTATION Joanna Wright Professional Coder Practicum

Medical Coding Medical coding is the transferring diagnostic and treatment terms from doctors and other health professionals into coded form for record keeping

REDUCES RISK MANAGEMENT EXPOSURE FOUR REASON TO DOCUMENT PROPERLY RECORDS CMS HOSPITAL QUALITY INDICATORS AND PQRS MEASURES COMMUNICATES WITH OTHER HEALTH CARE PERSONNEL ENSURES APPROPRIATE REIMBURSEMENT

PROPER HISTORY AND PHYSICAL PROGRESS NOTES DOCUMENTATION IS: CONSULTATIONS REPORTS ORDERS ATTENDING PROPER DOCUMENTATION PHYSICIAN DOCUMENTATION ANESTHESIA REPORTS PATHOLOGY REPORTS RADIOLOGY REPORTS DISCAHRE SUMMARRY

The patient is suffering from invasive ductal carcinoma of the right breast. the patient is 57 years old female with an extensive surgical history involving her bilateral breasts including prior mastopexies as well as breast augmentation. The patient was brought to the preoperative area and was marked for an inferior pedicle wise pattern reduction. According to the coding summary provided by supervisor all the information such as reason for visit, primary diagnosis, secondary diagnosis, procedural details, cancer follow up information, pertinent laboratory tests, medical history, current medication list, and symptoms of disease is present for this case. All the information is present for coder and there is no missing data for this patient. CASE # 410057

CODES FOR CASE 410057 CODES FOR THIS CASE: 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 19301-RT Partial Mastectomy (RT Right side of body) 14301 Adjunct tis transfer/rearrangement 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)

This patient a male 70 years of age; Multiple polyps resected diagnosed as tubulovillous adenomas and tubular adenomas. Colonoscopy with endoscopy mucosal resection. Patient states not all areas were completed, the doctor diagnosed the disease all proper documentation is present, and ready for coder. CASE 410092

CODES FOR 410092 Primary Diagnosis: D12.2 Benign neoplasm of ascending colon Secondary Diagnoses: I10 Essential (primary) hypertension E11.9 Type 2 diabetes mellitus without complications J45.909 Unspecified asthma, uncomplicated E03.9 Hypothyroidism, unspecified K21.9 Gastro-esophageal reflux disease without esophagitis E78.0 Pure hypercholesterolemia ( THIS CODE SHOULD HAVE BEEN ADDED)

The patient had the cyst at the site many years ago and recently she has noticed the scar has enlarged, become itchy and at times drains foul smelling material. The female patient is 49 years old and has no other medical condition. The medical notes contain the diagnosis, past medical history, past surgical history, medication details, family history, social history, anesthesia complication, physical exam details, assessment, plan, and detail of the procedure performed on patient. There was no occupational history available in the file. There were no lab tests mentioned in the file which can be used by coder while documentation. CODE 410198

Dx Reason for Visit: L72.0 Epidermal cyst Primary Diagnosis: L72.0 Epidermal cyst CODES FOR 410198 Secondary Diagnoses: E03.9 Hypothyroidism, unspecified E22.1 Hyperprolactinemia D35.2 Benign neoplasm of pituitary gland D64.9 Anemia, unspecified ( CODE THAT SHOULD HAVE BEEN ADDED)

CASE 410296 The patient is 45 years old man who presents with profound development delay and autistic behavior. He is unable to tolerate necessary dental treatment while conscious. The decision was made to utilize general anesthesia for completion of all necessary dental treatment in one appointment. The medical report contained information regarding patient s medical history, diet details, medication details, wound care instructions, follow up details, operation performed details, anesthesia complication, procedural details, and record of completed medication. Preoperative diagnosis, and postoperative diagnosis were missing in the case file.

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 CODES FOR 410296 Secondary Diagnoses: F79 Unspecified intellectual disabilities F84.0 Autistic disorder G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus E78.5 Hyperlipidemia, unspecified K04.7 Periapical abscess without sinus

REFERENCES https://www.aapc.com/medical-coding/medical-coding.aspx https://www.aapc.com/medical-coding/medical- coding.aspx https://www.aapc.com/medical-coding/medical-coding.aspx https://www.scp-health.com/providers/blog/think-with-your-ink-4-reasons-why-proper-medical-record-documentation-is-vital https://www.scp-health.com/providers/blog/think- with-your-ink-4-reasons-why-proper-medical- record-documentation-is-vital https://www.scp-health.com/providers/blog/think-with-your-ink-4-reasons-why-proper-medical-record-documentation-is-vital https://www.scp-health.com/providers/blog/think-with-your-ink-4-reasons-why-proper-medical-record-documentation-is-vital