Medical coding

User Generated

anaplJ

Health Medical

Description

You are performing the tasks of a chart auditor. To complete the Chart Audit activity, review the chart and coding abstract below. Complete the form indicating if you agree or disagree with the coding and the MS-DRG. If you do not agree with the assigned codes, include your corrected code and/or rationale in the spaces provided.

The MS-DRG must be verified using the encoder software. Codes can be verified using either the code book or encoder.

Use the attached Medical Record to complete the Worksheet attached

****MUST BE IN ICD 10 NOT ICD 9*****

Unformatted Attachment Preview

                                            &      &                                                                                                                                                                                   Instructions Assume you are a quality auditor. Using the case study provided, determine whether the hospital inpatient coder assigned the correct ICD-10-CM codes and sequenced them properly per UHDDS definitions. 1. Review all codes for accuracy and enter your findings as follows: a. If the code is correct and no change is needed, enter a “C” in the assessment column b. If a code is missing, add it to the reviewer code column (next to the last available/blank Facility Code space) and place an “M” in the assessment column c. If you identify an incorrect code (i.e. wrong specificity, missing digit etc.) is reported, enter the correct code into the reviewer code column (in the field next to the wrong code) and enter “I” in the assessment column d. If the code needs to be deleted because it is either not supported by documentation or because it is not reportable based on the UHDDS definition place an “X” in the assessment column. e. Additional rows as needed (right click>insert row below) 2. Record your explanation of the error in the review comments space provided. 3. Evaluate whether the correct condition has been designated as the principal diagnosis 4. Validate the MS-DRG 5. Submit this assessment as directed on or before the designated due date. DATA ELEMENT FACILIT Y CODE Admitting Diagnosis Principal Diagnosis G20 Secondary diagnoses #1 I63.9 #2 R42 F10.21 #3 K59.0 #4 R42 #5 E87.8 #6 M25.551 #7 F10.10 #8 Z87.81 #9 #10 MS-DRG Comments: 057 REVIEWER CODE ASSESMENT C, I, M,X REVIEWER COMMENTS
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Explanation & Answer

Attached.

Instructions
Assume you are a quality auditor. Using the case study provided, determine whether the
hospital inpatient coder assigned the correct ICD-10-CM codes and sequenced them properly
per UHDDS definitions.
1. Review all codes for accuracy and enter your findings as follows:
a. If the code is corr...


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