Abstract the pertinent clinical documentation and to determine the accurate procedural codes

Use the case analysis procedural coding template per case to abstract the pertinent clinical documentation and to determine the accurate procedural codes.

Abstract the pertinent clinical documentation and to determine the accurate procedural codes
Use the case analysis procedural coding template per case to abstract the pertinent clinical documentation and to determine the accurate procedural codes.

Explain the process of identifying each character to generate the correct
procedure code.

Apply the provided ICD-10-CM coding guidelines to determine the accuracy of the procedure codes.

Explain the importance and use of medical terminology and clinical vocabulary to procedural coding. Recommend the applicable AHIMA Code of Ethics for each case.

Determine the impact of coding quality and facility
Note: Using template attached for for the case study.

More so, using the same template for each case study. So using the template 4 time, the same questions are to be answer for all four case study.

More Details:

The absence of complete documentation in patient medical records can have a negative effect on statistical databases, financial planning, clinical preparedness, and gross revenue for the healthcare organization.

Also, it is for this reason that every healthcare organization should be focused on ensuring accuracy and completeness in clinical documentation, at any cost.

More so, documentation improvement is not a new concept in healthcare, but rather an evolving trend.

THE HEALTHCARE SYSTEM IN THE US IS CONSTANTLY CHANGING.
Firstly, from a clinical perspective, we have seen a movement away from postponing care until patients are severely ill and in need of hospitalization to preventive medical care.

Along with this trend, we have seen fewer, but more severe inpatient admissions and an increase in outpatient admissions over the past decade.

Second, from an information management viewpoint, there has been an increasing trend toward computerization of medical records.

Also, the government has responded to this trend by implementing privacy and security protections through HIPAA legislation.

Thirdly, reimbursement to healthcare providers for services has evolved. Many of the initial changes were triggered by HIPAA legislation as well.

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