critical elementsFor this project, you will review a patient record and apply the appropriate diagnosis and procedure coding. You will also provide a rationale that communicates how you arrived at your decision for a particular code.

Note: The patient record you will use for the final project is not the same record you will use for the milestones.

Specifically, the following critical elements must be addressed:

I. ICD-10: In this section, you will review the patient medical record and apply the appropriate ICD-10 coding to the diagnosis. You will also be asked to provide your rationale for how you arrived at a particular code.

A. Review the chart notes and determine a diagnosis. Explain how you arrived at your determination.

B. Determine the primary and secondary diagnosis. Describe what led you to this determination.

C. Identify the main term(s) for each diagnosis and provide a rationale to support your response.

D. Use an encoder and search for the main term of the diagnosis. 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.

E. Describe how you narrowed down your diagnosis selection based on descriptions and adjectives while using the encoder. Provide the narroweddown list to support your response.

F. Assign the diagnosis code to the record and explain why this code is the most appropriate for this diagnosis.

II. 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.

A. Review the chart notes and determine the HCPCS II procedure. Explain how you arrived at your determination.

B. Identify the main term(s) for each HCPCS II procedure and provide a rationale to support your identification.

C. 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.

D. 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.

E. Assign the HCPCS II procedure code to the record and explain why this code is the most appropriate for this procedure.

III. CPT: In this section, you will review the patient medical record and apply the appropriate CPT coding to the procedure(s). You will also be asked to provide your rationale for how you arrived at a particular code.

A. Review the chart notes and determine a CPT procedure. Explain how you arrived at your determination.

B. Identify the main term(s) for each CPT procedure and provide a rationale to support your identification.

C. Use an encoder and search for the main term of the CPT procedure. Describe the results of the search and the process applied to effectively use the encoder.

D. Describe how you narrowed down your CPT procedure selection based on descriptions and adjectives while using the encoder. Provide the narrowed-down list to support your response.

E. Assign the CPT procedure code to the record and explain why this code is the most appropriate for this procedure.

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