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[answered] About The coding application provides you the opportunity t


????????? About

The coding application provides you the opportunity to apply the coding skills you?ve learned this week.? As the courses progress and your skills increase, the rigor of the coding application will increase as well.? Every professional coder will tell you the more you code, the better coder you become so practice, practice, practice.??

To do well on the coding application, you must read the assigned chapters and complete the exercises in your textbook.? It is recommended that you look over the questions before reading the case scenario to give you an idea of what information you will be asked to answer.? Be sure to read every question completely as some are asking for a written response while others are asking you to assign a code.?

????????? Steps for Coding

Steps for correct CPT coding:

  • Determine the procedure, test, or service to be coded
  • Identify all terms
  • Locate each main term in the Alphabetic Index
  • Review and select the subterms indented below the main term
  • Note the code number(s) found opposite the selected main term or subterm
  • Verify the code in the Tabular List
  • Review coding notes and coding conventions
  • Determine modifiers when applicable
  • Repeat steps for additional code(s)

Steps for correct ICD coding:

  • Identify all terms in the diagnosis
  • Locate each main term in the Alphabetic Index.
  • Refer to any subterms indented under the main term.
  • Follow cross-reference instructions if the needed code is not located under the first main entry consulted.
  • Verify the code in the Tabular List.
  • Read and be guided by any instructional terms in the Tabular List.
  • Assign codes to the highest level of specificity.
  • Code the diagnosis until all elements are completely identified.

(See next page to continue)

Coding Test:

45 points

Directions:

  • Read the following Case Scenario
  • Using your ICD-10-CM, CPT, and HCPCS coding manuals, answer the questions in Parts 1 through 4 below for this scenario.

* NOTE: Be sure to assign an external cause code to indicate how the injury occurred.

CASE SCENARIO:

LOCATION: Inpatient, Hospital

PATIENT: Tara Barron

ATTENDING PHYSICIAN: Gary Sanchez, MD

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Stab wound, right upper abdominal quadrant.

POSTOPERATIVE DIAGNOSIS: Same as Preoperative.

PROCEDURE PERFORMED: Exploration of stab wound, right upper quadrant of abdomen, with closure of fascial defect.

ANESTHESIA: General.

PROCEDURE: The patient was brought to the operating room and placed under general anesthesia; we then removed the jar lid from around the knife as well as the patient?s clothing, and prepped with Betadine solution. We extended the incision on either side of the right upper quadrant stab wound 2-3 cm and carried the dissection through subcutaneous tissues using electrocautery. We followed the knife down along its tract and then could see the knife had penetrated the anterior sheath and the rectus fascia by about a quarter inch. We removed the knife and could see the tip was just within the rectus muscle. There was no peritoneal penetration. We then closed the fascia with interrupted 0 Vicryl and closed the skin with vertical mattress 3?0 Ethilon sutures.

All sponge and needle counts were correct. Patient tolerated this well and was taken to recovery in stable condition.

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?PART 1: Abstracting

  • What is the name of the physician performing the procedure? (1 point)

Gary Sanchez, MD

  • What is the procedure, test, or service to be coded? ?(2 points)

Hospital, Inpatient-

  • What is the documented size of the wound? (1 point)

2-3 cm

  • What tissue has been damaged as reported by the physician? ?(2 points)

the right upper quadrant

  • Does the depth of tissue effect the code choice?? If yes, how does the depth effected tissue determine the choice of code for services? ?(2 points)

Type answer here

  • Was skin grafting performed? (2 points)

no

  • Is the closure of the wound site reported separately?? Briefly explain ?why? or ?why not? the closure would or would not be reported separately.? (2 points)

Type answer here

(See next page to continue)

PART 2: Surgical Procedure

  • What are all possible terms for the surgical procedure used in the Alphabetic Index of the CPT coding manual? (2 points)

Type answer here

  • What subterm(s) are identified under the main term in the Alphabetic Index? (1 point)

Type answer here

  • What code(s) are listed in the Alphabetic Index? (1 point)

Type answer here

  • What section in the Tabular List of the CPT manual did you find the code(s)? (1 point)

Type answer here

  • Are there any relevant guidelines or parenthetic notes associated with the procedure code that should be referenced? (1 point)

Type answer here

  • Briefly describe what services are? included? in the procedure according to the guidelines preceding the code choice for this procedure? (2 points)

Type answer here

PART 3: Diagnosis

  • What is the documented condition to be coded? (1 point)

Type answer here

(See next page to continue)

  • What is the main term in the ICD-10-CM Alphabetic Index? (1 point)

Type answer here

  • What is the subterm that identifies the condition? (1 point)

Type answer here

  • What, if any, are the additional subterms you need to reference? (1 point)

Type answer here

  • Are there any cross reference instructions in the Alphabetic Index that should be followed? (1 point)

Type answer here

  • What code (s) are listed for the condition in the index? ?(1 point)

Type answer here

  • Are there any instructional notes in the Tabular List that should be followed? ?(1 point)

Type answer here

  • What is the documented external cause for the condition to be coded? (1 point)

Type answer here

  • What is the name of the index referenced for the external cause code? (1 point)

Type answer here

  • What is the main term in the ICD-10-CM External Cause Index? (1 point)

Type answer here

(See next page to continue)

  • What is the subterm that identifies the specific external cause? ?(1 point)

Type answer here

  • Are there any cross reference instructions in the External Cause Index that should be followed? (1 point)

Type answer here

  • What code (s) are listed for the condition in the index? (1 point)

Type answer here

  • Are there any instructional notes in the Tabular List that should be followed? (1 point)

Type answer here

  • Have all documented diagnoses been identified for this scenario? (1 point)

Type answer here

PART 4: Assigning Codes

  • What is the CPT code for the procedure? (3 points)

Type answer here

  • What is the ICD-10-CM code for the first listed diagnosis? (3 points)

Type answer here

  • What is the additional ICD-10-CM code reported for this encounter? (3 points)

Type answer here

  • Have all identified procedures, services and diagnoses been reported with these codes? ?(1 point)

Type answer here


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