281 Chapter 13 Diagnostic Coding Essentials Procedure 13.1 Perform Coding Using the Current ICD-10-CM Manual or Encoder

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281 Chapter 13 Diagnostic Coding Essentials Procedure 13 1 Perform Coding Using The Current Icd 10 Cm Manual Or Encoder 1 (62.42 KiB) Viewed 167 times

281 Chapter 13 Diagnostic Coding Essentials Procedure 13.1 Perform Coding Using the Current ICD-10-CM Manual or Encoder Name Date Score Task: To perform accurate diagnosis coding using the ICD-10-CM manual or encoder. Scenario: The encounter form and progress notes both show that the diagnosis for this patient encounter is acute colitis. Locate the most accurate ICD-10-CM code for this diagnostic statement Equipment and Supplies: ICD-10-CM manual (current year) or Encoder software such as TruCode Standard: Complete the procedure and all critical steps in minutes with a minimum score of 85% within two attempts (or as indicated by the instructor) Scoring: Divide the points earned by the total possible points. Failure to perform a critical step, indicated by an asterisk (*), results in grade no higher than an 84% (or as indicated by the instructor). . Time: Began Ended Total minutes: Point Value Attempt 1 Attempt 2 10 10 10 15 10 10 Steps: Alphabetic Index 1. Determine and locate the main terms from the diagnostic statement in the Alphabetic Index 2. Locate the essential modifiers listed under the main term in the Alphabetic Index 3. Review the conventions, punctuation, and notes in the Alphabetic Index. 4. Choose a tentative code, codes, or code range from the Alphabetic Index that matches the diagnostic statement as closely as possible. Tabular List S. Look up the codes chosen from the Alphabetic Index in the Tabular List 6. Review notes, conventions, and the Official Coding Guidelines associated with the code and code description in the Tabular List. a. Review conventions and punctuation. b. Review instructional notations: • Includes and excludes notes Code first code also, and code additional notes . and, or, and with statements 7. Verify the accuracy of the tentative code in the Tabular List. a. Make sure all elements of the diagnostie statement are included in the codes selected b. Make sure the code description does not include anything not documented in the diagnostic statement 8. Extend the codes to their highest level of specificity (up to the 7th character, if required). If a 7th character is required, and no codes are present for the 4th, 5th, or oth characters, it is appropriate to use the dummy placeholder X for these positions. 10 10