I attached the document and my lab for this assignment. let me know if it is difficult or not.
Coding Audit
Prior to beginning work on this assignment, log in and review the VLAB Nuance Quantim or 3M Encoder. You will need information from these pages to complete the tables in the assignment.
Tracy Barret is the new coding section supervisor and wanted to do a quick assessment of her coding staff’s coding skills. Below is the discharge summary.
Ms. Albertino is a 69-year-old female with known coronary artery disease, status post CABG (coronary artery bypass grafting) on 5/15/XY, two-vessel disease, also aortic valve replacement. She is currently on Coumadin. The patient was admitted to the hospital 3 weeks ago for a myocardial infarction. She complained of shortness of breath and chest pain and was admitted as a result. She was not placed on any heparin drips or nitroglycerin drips. She was started on Isordil 30 mg b.i.d., as well as given nitro 50 mg t.i.d. and Norvasc 5 mg once a day. She states that she has been using nitro daily since discharge, and has chest pain at rest, at night time, or during exertion. She did not have a heart catheterization during this hospitalization, and was discharged secondary to cost.
OBJECTIVE: Vital signs: Blood pressure 154/69, weight 173, temperature 97.6, pulse 59, respirations 19. Oxygen saturation is 97% on room air. Neck is supple with no lymphadenopathy. Heart has regular rate and rhythm with an aortic click, no murmurs. Lungs are clear to auscultation bilaterally. Decreased breath sounds throughout. Abdomen is soft, nontender, nondistended with positive bowel sounds. Extremities: No peripheral edema; however, she has weak peripheral pulses bilaterally.
ASSESSMENT
- Unstable angina.
- Known coronary artery disease status post coronary artery bypass grafting.
PLAN: We will go ahead and order a resting EKG (electrocardiogram) for one week from today.
Coder
Principal Diagnosis (ICD10CM)
Diagnosis
Diagnosis
Diagnosis
Diagnosis
CPT
Findings
Correct or Incorrect
MS DRG
1
I21.3
I25.110
Z79.01
Z95.1
Z95.2
94760
2
I25.110
I21.3
Z79.01
Z95.1
94762
3
I21.3
I25.110
Z79.01
Z95.1
94760
4
I21.3
I25.110
Z79.01
Z95.1
Z95.2
94750
5
I21.3
I25.110
Z79.01
Z95.1
94760
For this assignment, prepare a summary of the audit with the following information:
- The correct codes for the scenario.
- Using the VLab Nuance Quantim or 3M Encoder, determine the MS DRG based on the codes of each coder.
- Complete the table.
- Identify for each coder, any errors in the code assignment.
- Include the coding guideline not followed for any errors identified.
- Determine the coding accuracy rate (number of coders who coded the case correctly) divided by the number of coders.
- Prepare a two- to three-sentence summary of your findings.
Based on the findings of the above review, prepare a coding audit proposal in which you indicate the following:
- The number of charts to be coded.
- The frequency of the coding review.
- Your plan of action to address variations in coding.
The Coding Audit assignment
- Must be two to three double-spaced pages in length (not including title and reference pages) and formatted according to APA style as outlined in the Writing Center (Links to an external site.).
- Must include a separate title page with the following:
- Title of paper in bold font
- Space should appear between the title and the rest of the information on the title page.
- Student’s name
- Name of institution (The University of Arizona Global Campus)
- Course name and number
- Instructor’s name
- Due date
- Title of paper in bold font
- Must use at least one scholarly source in addition to the course text.
- Must document all sources in APA style as outlined in the Writing Center (Links to an external site.).
- Must include a separate reference page that is formatted according to APA style as outlined in the Writing Center.
Carefully review the Grading Rubric (Links to an external site.) for the criteria that will be used to evaluate your assignment.
Expert Solution Preview
Introduction:
The Coding Audit assignment requires a summary of a discharge summary and determining the correct codes, MS DRG, any coding errors, coding guidelines not followed, coding accuracy rate, and a two to three-sentence summary of the findings. It also requires a coding audit proposal indicating the number of charts to be coded, the frequency of the coding review, and a plan of action to address variations in coding.
Answer:
The Coding Audit assignment requires a thorough understanding of medical coding and compliance with the coding guidelines. It is essential to log in and review the VLAB Nuance Quantim or 3M Encoder to prepare the audit. The correct codes for the scenario must be determined, and MS DRG should be identified based on the codes of each coder. The table should be completed, and coding errors should be identified along with coding guidelines not followed for any errors identified. The coding accuracy rate must be calculated based on the number of coders who coded the case correctly divided by the number of coders. A two to three-sentence summary of the findings must be prepared.
Based on the findings of the above review, a coding audit proposal should be prepared that indicates the number of charts to be coded, the frequency of the coding review, and the plan of action to address variations in coding. The proposal must specify the steps to be taken to improve the accuracy of the coding and ensure compliance with the coding guidelines.
In conclusion, the Coding Audit assignment is an important exercise for medical students to understand medical coding and compliance with the coding guidelines. It helps them to identify coding errors, address variations in coding, and improve the accuracy of the coding. It is essential to log in and review the VLAB Nuance Quantim or 3M Encoder to prepare the audit accurately.
