HIM2944-Module-02-Coding-Assignment-LInked-Document
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Rasmussen College *
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Feb 20, 2024
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Directions: The purpose of this assignment is for you to exhibit your critical thinking skills by coding the medical chart. You are also required to complete the assignment by using the 3M encoder. Provide a screenshot from 3M of your work for questions 1 and 5. Your professor will evaluate your answers for coding guideline usage, communication from individual perspective, coding abstraction, sequencing and 3M encoder usage. Please provide all answers in the appropriate boxes listed below the questions.
1.
What is the principal diagnosis? Acute Pyelonephritis, N10
What pathway did you take in order to code the condition properly? Please provide a screen shot of encoder usage for your answer.
2.
Given that you’ve provided the correct answer for question #1. Please list the instructional note listed in the tabular list to help support the ICD-10-CM code in question #1? Provide an explanation of why you feel the code listed for the principal diagnosis is appropriate. Use additional code (B95-B97) to identify infectious agent
Pyelonephritis is a UTI that involves one or both kidneys. The tabular instructs me to code the infectious agent with an additional code. E. Coli is stated in the summary, and lab reports are to be coded as secondary codes. Therefore, Pyelonephritis should be the principal diagnosis. 3.
In the History and Physical the patient complains of left upper flank pain should this condition be coded? What coding guideline supports your decision? Explain.
4.
In the family history section of the history and physical the physician documents, “she has a brother with mild epilepsy” should this be coded why or why not? Explain.
Flank pain is a symptom of pyelonephritis and should not be coded.Coding guideline B5 supports not coding left upper flank pain.
5.
Given that the principal diagnosis is listed for question #1, please list all secondary diagnoses and the pathways. Please list all appropriate codes and give the proper sequence of the codes listed. Please provide a screenshot of encoder usage for your answer.
How to do a Screen Shot in a 3M encoder:
1.
Once you have completed finding the code for the answer you need, put your curser on the screen.
2.
Hold down the CTRL (control) key and hit your PRT SC (Print Screen) key at the same time. (You will not see anything happen.
3.
Go to your word document and paste the screen shot in the place where you need to have your answer.
The family history of her brother with mild epilepsy does not need to
be coded as it does not pertain to her diagnosis and treatment of pyelonephritis. Coding guidelines in Section III A) state the history codes may be used as secondary codes if the historical condition or family history impacts current care or influences treatment. Infection
in the patient’s kidneys does not meet that requirement.
Secondary Diagnoses & Pathway:
If you need further help with taking a Screen Shot, please call the Personal Support Center at 1-866-693-2211. They are available 24/7 and can walk you through what to do.
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