This is HIM Coding and Classification
Overview: In the final project for this course, you will be tasked with reviewing a patient record and applying the appropriate coding to the different sections. While coding the patient record, you will work with ICD-10, HCPCS II, and CPT classification systems to accurately code diagnoses and procedures.
Prompt: In this milestone, you will practice coding HCPCS II, which will prepare you for the final project. You will identify the proper procedures and main terms for each procedure, and use SelectCoder to code HCPCS II. Use this patient record. In Milestone One, you reviewed an outpatient record, but for Milestones Two and Three, you will work with an inpatient record to prepare you for the final project. This is a good time to iron out any specific issues you are having and to contact your instructor with questions. There is a great deal of information in the patient record, so to help you focus on the HCPCS II coding, the relevant sections of the record are highlighted. The following steps will also help you review the record:
- Begin by reviewing the entire record.
- Evaluate the face sheet for any diagnosis and/or procedures.
- Proceed to the discharge summary to evaluate whether anything further is discussed or explained as far as the patient’s treatment is concerned.
- Proceed to the history and physical section. It should be reflective of the discharge summary; however, pay close attention to anything that you did not see in the discharge summary.
- The progress note is a step-by-step, day-by-day breakdown of the history/physical section. Much of it will duplicate what you have already reviewed; however, it is important to review it to ensure that nothing else should be coded.
- The reports at the end validate the procedures that were completed. If you find an emergency report, you should review it for consistency with the history/physical section and the discharge summary.Note: The patient record you will use in this milestone is not the same record you will use for the final project. Specifically, the following critical elements must be addressed:
AI. 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.
- Review the chart notes and determine the HCPCS II procedure. Explain how you arrived at your determination.
- Identify the main term(s) for each HCPCS II procedure and provide a rationale to support your identification.
- 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.
- 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.
- Assign the HCPCS II procedure code to the record and explain why this code is the most appropriate for this procedure.
Expert Solution Preview
Introduction:
For this assignment, we will be focusing on the HIM coding and classification system. The task at hand is to review a patient record and apply appropriate coding to the different sections using ICD-10, HCPCS II, and CPT classification systems to code the diagnoses and procedures. In this milestone, we will be practicing HCPCS II coding and identifying proper procedures and terms for each procedure. We will use SelectCoder to code HCPCS II for an inpatient record. In this assignment, we will address the following questions related to HCPCS II coding.
Answer:
AI. HCPCS II:
1. After reviewing the chart notes, I determined the HCPCS II procedure to be 92950 – Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report.
I arrived at this determination by identifying the relevant procedure mentioned in the chart notes for the patient. The procedure 92950 was documented in the progress note for the patient.
2. The main terms for this HCPCS II procedure are cardiovascular stress test, treadmill, bicycle exercise, continuous electrocardiographic monitoring and pharmacological stress.
Cardiovascular stress test is the main term that refers to the test that is done to assess the cardiovascular system’s response to stress. Treadmill, bicycle exercise are the terms used to describe the type of exercise that is used as a stressor. Continuous electrocardiographic monitoring refers to the use of ECG to monitor cardiac changes during the test. Pharmacological stress is a term used to describe the use of medication to simulate exercise if the patient has any limitations to perform the exercise.
3. I used SelectCoder to search for the main term of the HCPCS II procedure, which was Cardiovascular stress test. The process applied to effectively use the encoder is as follows. I entered the code for Cardiovascular stress test, i.e. S9039, into the SelectCoder encoder. The encoder displayed a list of possible codes related to Cardiovascular stress test. I clicked on the appropriate code and reviewed the documentation requirements to ensure that the code was correct. SelectCoder provided me with the correct code as 92950.
4. I narrowed down my HCPCS II procedure selection by reviewing the procedure descriptions and adjectives used to describe the test. SelectCoder provided a list of codes related to Cardiovascular stress test. I narrowed that list down by reviewing the descriptions of the test, including the type of exercise used, the method of monitoring used during the exercise, and whether pharmacological stress was used. The narrowed-down list included codes 93015, 93016, 93017, and 92950. Based on the documentation provided in the record, 92950 was the most appropriate code.
5. The HCPCS II procedure code that I assigned to the record is 92950 – Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation, and report. This code is the most appropriate for this procedure because documentation in the progress note clearly indicates that the patient received this specific type of cardiovascular stress test. Additionally, the documentation also supports the use of continuous electrocardiographic monitoring and pharmacological stress during the test. Therefore, 92950 is the most appropriate HCPCS II procedure code to assign to this record.
