HIM 215 SNHU HIM Coding and Classification
Assignment ID Number AFFGEHU83939HD Type of Document Essay Writing Format APA/MLA/Harvard Academic Level Masters/University References/Sources 4 References
This is HIM Coding and Classification
Overview: In the final project for this course, you will be tasked with reviewing a patient record and applying the appropriate coding to the different sections. While coding the patient record, you will work with ICD-10, HCPCS II, and CPT classification systems to accurately code diagnoses and procedures.
Prompt: In this milestone, you will practice coding HCPCS II, which will prepare you for the final project. You will identify the proper procedures and main terms for each procedure, and use SelectCoder to code HCPCS II. Use this patient record. In Milestone One, you reviewed an outpatient record, but for Milestones Two and Three, you will work with an inpatient record to prepare you for the final project. This is a good time to iron out any specific issues you are having and to contact your instructor with questions. There is a great deal of information in the patient record, so to help you focus on the HCPCS II coding, the relevant sections of the record are highlighted. The following steps will also help you review the record:
? Begin by reviewing the entire record.
? Evaluate the face sheet for any diagnosis and/or procedures.
? Proceed to the discharge summary to evaluate whether anything further is discussed or explained as far as the patients treatment is concerned.
? Proceed to the history and physical section. It should be reflective of the discharge summary; however, pay close attention to anything that you did not see in the discharge summary.
? The progress note is a step-by-step, day-by-day breakdown of the history/physical section. Much of it will duplicate what you have already reviewed; however, it is important to review it to ensure that nothing else should be coded.
? The reports at the end validate the procedures that were completed. If you find an emergency report, you should review it for consistency with the history/physical section and the discharge summary.Note: The patient record you will use in this milestone is not the same record you will use for the final project. Specifically, the following critical elements must be addressed:
AI. HCPCS II: In this section, you will review the patient medical record and apply the appropriate HCPCS II coding to the procedure(s). You will also be asked to provide your rationale for how you arrived at a particular code.
Review the chart notes and determine the HCPCS II procedure. Explain how you arrived at your determination.
Identify the main term(s) for each HCPCS II procedure and provide a rationale to support your identification.
Use an encoder and search for the main term of the HCPCS II procedure. Describe the results of the search and the process applied to effectively use the encoder. Note: You will use SelectCoder as your encoder for this task.
Describe how you narrowed down your HCPCS II procedure selection based on descriptions and adjectives while using the encoder. Provide the narrowed-down list to support your response.
Assign the HCPCS II procedure code to the record and explain why this code is the most appropriate for this procedure.
QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points: Student failed to submit the final paper. 20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. 40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. 50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). Zero points: Student failed to include citations and/or references. Or the student failed to submit a final paper. 5 out 20 points: Sources are seldom cited to support statements and/or format of citations are not recognizable as APA 6th Edition format. There are major errors in the formation of the references and citations. And/or there is a major reliance on highly questionable. The Student fails to provide an adequate synthesis of research collected for the paper. 10 out 20 points: References to scholarly sources are occasionally given; many statements seem unsubstantiated. Frequent errors in APA 6th Edition format, leaving the reader confused about the source of the information. There are significant errors of the formation in the references and citations. And/or there is a significant use of highly questionable sources. 15 out 20 points: Credible Scholarly sources are used effectively support claims and are, for the most part, clear and fairly represented. APA 6th Edition is used with only a few minor errors. There are minor errors in reference and/or citations. And/or there is some use of questionable sources. 20 points: Credible scholarly sources are used to give compelling evidence to support claims and are clearly and fairly represented. APA 6th Edition format is used accurately and consistently. The student uses above the maximum required references in the development of the assignment. Grammar (worth maximum of 20% of total points) Zero points: Student failed to submit the final paper. 5 points out of 20: The paper does not communicate ideas/points clearly due to inappropriate use of terminology and vague language; thoughts and sentences are disjointed or incomprehensible; organization lacking; and/or numerous grammatical, spelling/punctuation errors 10 points out 20: The paper is often unclear and difficult to follow due to some inappropriate terminology and/or vague language; ideas may be fragmented, wandering and/or repetitive; poor organization; and/or some grammatical, spelling, punctuation errors 15 points out of 20: The paper is mostly clear as a result of appropriate use of terminology and minimal vagueness; no tangents and no repetition; fairly good organization; almost perfect grammar, spelling, punctuation, and word usage. 20 points: The paper is clear, concise, and a pleasure to read as a result of appropriate and precise use of terminology; total coherence of thoughts and presentation and logical organization; and the essay is error free. Structure of the Paper (worth 10% of total points) Zero points: Student failed to submit the final paper. 3 points out of 10: Student needs to develop better formatting skills. The paper omits significant structural elements required for and APA 6th edition paper. Formatting of the paper has major flaws. The paper does not conform to APA 6th edition requirements whatsoever. 5 points out of 10: Appearance of final paper demonstrates the student’s limited ability to format the paper. There are significant errors in formatting and/or the total omission of major components of an APA 6th edition paper. They can include the omission of the cover page, abstract, and page numbers. Additionally the page has major formatting issues with spacing or paragraph formation. Font size might not conform to size requirements. The student also significantly writes too large or too short of and paper 7 points out of 10: Research paper presents an above-average use of formatting skills. The paper has slight errors within the paper. This can include small errors or omissions with the cover page, abstract, page number, and headers. There could be also slight formatting issues with the document spacing or the font Additionally the paper might slightly exceed or undershoot the specific number of required written pages for the assignment. 10 points: Student provides a high-caliber, formatted paper. This includes an APA 6th edition cover page, abstract, page number, headers and is double spaced in 12’ Times Roman Font. Additionally, the paper conforms to the specific number of required written pages and neither goes over or under the specified length of the paper.
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