jmontone_HIM2944-Module-02-Coding-Assignment-LInked-Document_01142024
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School
Rasmussen College, Saint Cloud *
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Course
2944
Subject
Medicine
Date
Feb 20, 2024
Type
docx
Pages
3
Uploaded by KidToad3548
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? 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.
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.
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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.
N10
The patient presented to the hospital with chief complaints of chills, fever, and feeling lousy. The patient also complained of tenderness in the abdomen under the left costal margin with no enlargement of any
organs. She has pain to percussion in the left upper flank area. These are classic signs of acute pyelonephritis. Urine culture grew
out Escherichia coli greater than 100,000 colonies.
B4. Signs and symptoms. Codes that describe symptoms and signs, as opposed to diagnosis, are acceptable for reporting purposes only when a related definitive diagnosis has not been confirmed by the provider, but in this case it has.
No, you would not code the family history of epilepsy in this case because the patient doesn’t have any related symptoms, so she isn’t considered to be at risk, however it is important that it is documented within the patient’s health record.
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.
Secondary Diagnoses & Pathway: N10, B96.20, E86.0
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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