For this assignment, you will learn about computer-assisted coding and practice using the computer-assisted encoder. Many encoders now have this feature to assist coders with coding. The CAC will use natural language processing to suggest diagnoses and procedures/surgeries that should be coded. The coder then acts as an editor and determines which suggested codes should actually be coded on the chart. Complete the TWO parts of this assignment.
1) Follow the instructions on this attached CAC Assignment file and determine the correct coding for this case. Refer to the Official Guidelines for Coding and Reporting ICD-10-CM and ICD-10-PCS and use them to decide on the correct coding. State why and what corrections are made and state which coding guideline applies to each of your corrections. (Official Guidelines for Coding and Reporting can be found in the reference section of 3M in AHIMA Vlab or in your coding manuals for ICD-10-CM and ICD-10-PCS).
2) Using AHIMA Vlab Nuance (see announcement for AHIMA Vlab Encoders).
- Login to AHIMA Vlab and choose Nuance Clintergy. Review the FAQs and the Vlab Login Credential for using Nuance Cintergy.
- Launch Nuance Clintergy.
- Do assignments #1 Getting Started and #3 ICD-10 Lab,
- Submit grade screenshots of your passing score (85 or higher) for each assignment in one document.
To make a screenshot:To do a screenshot on a Microsoft computer, use the CTRL key and the PRTSCR key, press down on both at the same time, lift your fingers and go to a blank Word page. Use the CTRL and V keys and paste the screenshot onto a Word document. For a Mac, you can use shift + command + 4.Put all screenshots on one page and submit as proof of coding for your assignment. Save Word document and submit.
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COMPUTER ASSISTED CODING ASSIGNMENTS – TWO PARTS
For this assignment, you will learn about Computer Assisted Coding and practice using the simulated computer assisted encoder (CAC). Many encoders now have this feature to assist coders with coding. The CAC will use natural language processing to suggest diagnoses and procedures/surgeries that should be coded. The coder then acts as an editor and determines which suggested codes should actually be coded on the chart.
The Computer Assisted Coding encoder will scan the record and highlight words in an EHR that it thinks should be coded. The coder then will evaluate each shaded word to determine if that highlighted word is part of this case and should be coded or whether it should not be coded. Things to consider are: it is part of this current care/case, is it a part of an old history not related to this case, is it part of a comment that does not apply to this case, or is it part of a physician copy and paste from an old record, etc.
Part One:
A. Read the following report from a patient record that has been processed with computer assisted coding (CAC) encoder software.
B. Determine any areas of inaccuracy in the CAC codes identified in the list below.
C. Following all official coding guidelines, recommend corrections to the CAC code assignment below. What code should be the principal diagnosis and which codes should be the secondary diagnoses? Should any codes not be used? Sequence codes accordingly and indicate those that should not be used for this case.
D. Make and submit your own list of correct codes indicating any below that should be deleted, list in correct order any codes that should be sequenced differently and explain why. Explain if you changed the principal diagnosis and why. Indicate which official coding guidelines that you used in making these decisions.
Mr. Mayberry is a 62-year-old Caucasian male admitted with chest pain. He states that he developed this pain after lifting heavy objects while cleaning his garage. He ranks his pain as an 8 out of 10 on the pain scale. He has no arm or jaw pain.
He has been treated for hyperlipidemia, and hypertension, on medication for both conditions for the last 10 years. Past history reveals that 11 months ago, he suffered an acute myocardial infarction and was treated with stents.
Today, an EKG was performed and cardiac enzymes drawn. All results were normal. The patient
exhibited the pain upon movement and palpation at the chondrosternal joint and a final
diagnosis of sprain was determined.
Codes assigned by CAC encoder:
R07.9
I21.3
R68.84
S23.421A
I10
E78.5
Resources:
https://www.himss.org/news/computer-assisted-coding-cac-solutions
http://library.ahima.org/doc?oid=106663#.W9JFJGhKhPY
Part Two:
Using AHIMA Vlab Nuance (see announcement for AHIMA Vlab Encoders).
A. Login in to AHIMA Vlab and choose Nuance. Review the FAQs and the Vlab Login Credential in the Resource section.
B. Launch Nuance Clintergy, DO NOT Change the password use what is given to you in VLab and by your Professor.
C. Do assignments #1 Getting Started and #3 ICD-10 Lab,
D. Submit screenshots of your passing score for each assignment.