HIM1103. Module02. LiveLecture

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Rasmussen College, Florida *

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1103

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Mechanical Engineering

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Dec 6, 2023

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Module 02 ICD-10-CM Coding An In-Depth Look at How to Code for Diagnosis Documentation The 3M Encoder will be introduced for ICD-10-CM Coding

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 2 • This week it will be important to do your reading assignment from the code book (ICD-10-CM pg. 1-54) and the Blackboard reading material. Also listen to the Live Classroom session before doing any of the assignments. • The reading in the code book is critical in helping you to understand how the code book is structured and the coding guidelines are organized as well as how to apply them to the diagnostic statements. • It is not intended for you to memorize all of the information. It is important, however, to become familiar with the guidelines and instructions to be able to find the information when needed to code correctly and code according to guidelines. Module 02 Reading Assignment

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 3 • Data set for inpatient admissions and all other non-outpatient settings • Coded data has many uses e.g. clinical reports, statistical analysis, billing and research to name a few. • For data to be useful, there must be consistency in the collection process. • UHDDS was created to establish a minimum data set to improve uniformity and comparability of hospital discharge data (Schraffenbergerer & Palkie, 2020). • UHDDS definitions include Diagnoses, Principal Diagnosis, Other Diagnoses, Complications, Comorbidity, Significant Procedure, and Principal Procedure and more. • The UHDDS definitions along with the Official Coding Guidelines are to be followed when coding all non-outpatient cases (long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc.) • Coders are responsible for ensuring all coded data is reliable. Uniform Hospital Discharge Data Set (UHDDS)

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12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 4 • There are basic concepts and rules that a coder must understand and apply when assigning ICD-10- CM codes in order to be ethical, compliant, and accurate for reporting purposes (Schraffenbergerer & Pelkie, 2020). • For ICD-10- CM there are “General Coding Guidelines” and “Chapter Specific Guidelines”. • Review the guidelines in the ICD-10-CM code book. Official Coding Guidelines

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential General Coding Guidelines : • How to …locate the guidelines in the front of the code book-Section I B. • How to... locate a code and level of specificity (pg. 12) • How to… code borderline diagnoses (pg. 17) • How to …choose the Principal Diagnosis for inpatient coding-Section II (pg. 105) • How to… report additional diagnosis- Section III (pg. 107) • How to …code and report Outpatient Services-Section IV (pg. 109) Chapter Specific Coding Guidelines: • Located in Section I C of the code book. • Contains specific guidelines for specific chapters in the Tabular List. • Guidelines are also located in the Tabular List of Diseases and Injuries at the beginning of the respective chapters. 5 Coding Guidelines

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 6 Read and follow the steps given in Lesson Content under “ICD - 10- CM Coding Steps” and in the code book for a more in depth understanding of ICD-10- CM coding. Read also the “Key Terms” in your course. Remember, learning to code is a skill that requires practice. Learning to code is like learning a foreign language. ICD-10 Coding Steps In Depth

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12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 7 • Double check the provider’s documentation against the final code determined. Make sure they match as closely as possible, that all characters are assigned, and that you have coded to the greatest degree of specificity. • Before finalizing a code, read the Tabular List Instructions and your Chapter Specific Guidelines. • For all coding, make sure you are following the General Coding Guidelines. CODING TIPS

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 8 Documentation: Gastroenteritis due to Salmonella. Identify the Main Term: Main Term is Gastroenteritis. (Also called enteritis) Identify the Subterm: Subterm is Salmonella as that is the cause of the gastroenteritis. Look up the Main Term, followed by the Subterm in the Alphabetic Index Code given is A02.0 Look up A02.0 in the Tabular List (Chapter 1) category A02 for other Salmonella infection. Choose the addition of the zero because enteritis means the same as gastroenteritis. Reference medical terminology and other resources to further your understanding of the clinical terms used by the providers. Let’s Practice Coding ICD -10-CM

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 9 Documentation: CHF (Congestive Heart Failure) • Identify the Main • Identify the Subterm • Look up the Main Term followed by the Subterm in the Alphabetic Index. • Note the code given following the subterms • Look up the code given in the Tabular List. – Read all instructions. – Apply any General Coding Guidelines – Reference the Chapter Specific Guidelines Your Turn to Practice Coding ICD-10-CM

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12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 10 Documentation: CHF (Congestive Heart Failure) • Main Term is failure. • Sub term is heart and then congestive. • Alphabetic Index: Given: I50.9 • Tabular List: I50.9 Read instructions. – I50.9 is for Heart Failure, unspecified . • Note there is a list of diagnoses which are included for this code. CHF NOS (Not Otherwise Specified) is listed. However , CHF unspecified fits this documentation. It is unspecified or NOS because there is no further documentation given for specifics. Check Your Answer--

Introduction to the 3M Encoder for ICD-10- CM coding: An encoder is coding software used to locate codes and is used by a coder. The 3M is a logic-based encoder and requires answering questions pertaining to the documentation being coded to access the correct code or codes. Reminder: Diagnosis codes are used for both outpatient and inpatient coding.

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 12 • The Rasmussen College 3M Encoder is accessed via the website: www.my.ahima.org • The encoder is made available the national AHIMA organization. • If you experience problems getting in, try the following: – Try another browser – Enter the website address manually into the browser – Turn off pop up blockers – Sundays tend to have heavy use which may cause problems. Wait 15 minutes and try again. – If problems still occur, contact the AHIMA Help Desk or your instructor-DO NOT contact PSC as they are not familiar with the encoders. How To Access the 3M Encoder

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12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 13 • Visit the Encoder Software Resources webpage and study the resources listed below. – Encoder Software Resources https://guides.rasmussen.edu/healthsciences/encoderr esources • Instructions for Using the 3M Encoder through Rasmussen • Video Demonstration of the 3M Encoder 3M Encoder Demonstration

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential Makes a Skilled Coder Read Slowly Practice Ask Questions • Learning to code takes time and practice (lots of practice). • Ask questions of the instructor if you don’t understand. • Request assistance from Tutoring — ask your instructor for instructions on how to access tutoring. • Read all diagnostic documentation carefully…and slowly. • Look up unfamiliar medical terms. • Remember you are learning a skill, like learning a new language. 14 Reminders for Module 02

Any Questions? For the Live Session, ask your Instructor any questions now. For the Recorded Session, ask your Instructor questions via Course Email or General Course Questions.

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12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 16 Submission of the Assessment Responses Indicates you….. - Listened to the recorded lecture or participated in the live classroom session - Are accountable for the information contained in the lecture materials Responses to the Assessment Questions need to come from the information presented in lecture . Remember your Assessment Response!

12/1/16 Copyright Rasmussen, Inc. Proprietary and Confidential 17 Schraffenberger, L. A., & Palkie, B. N. (2020). Basic ICD-10-CM and ICD-10- PCS Coding. Chicago, IL: AHIMA Press, American Health Information Management Association. References