Graded Project

Graded Project

Intermediate Medical Coding

OVERVIEW 1

WRITING GUIDELINES 1

INSTRUCTIONS 2

GRADING CRITERIA 4

SUBMITTING YOUR PROJECT 5

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OVERVIEW As a medical coder, you’ll assign CPT codes for physician procedures and services. This graded project is designed to

1. Test your knowledge of CPT coding principles and procedures

2. Gauge your ability to accurately apply coding guidelines with regard to CPT codes and modifiers

3. Analyze your accuracy with respect to HCPCS code assignment

4. Determine your ability to differentiate CPT and HCPCS

5. Summarize what you’ve learned about CPT and HCPCS coding

WRITING GUIDELINES 1. Open a new Word document and include the following

information at the top of your graded project:

n Name and address

n Student number

n Course title and number (HIT204, Intermediate Medical Coding)

n Research project number (38166000)

2. Copy and paste all exam questions into the Word docu- ment and add answers after reading the assignment and following the instructions carefully.

Intermediate Medical Coding

Intermediate Medical Coding 2

3. After completing the exam, click on File, Save As, Documents, name the file and click Save.

4. Follow the directions on the last page of this assignment to submit your project.

INSTRUCTIONS Your graded project has three parts. Be sure to complete all three parts prior to submitting your project.

Part 1 Review the following scenario. Assign the CPT code(s). Add one or more modifiers, if necessary.

A 71-year-old male patient comes to the hospital after having been previously diagnosed with benign prostatic hypertrophy with urinary obstruction. Due to this condition, the patient is experiencing increased urination, straining during urina- tion, and a continual feeling of fullness after the bladder has been emptied. The physician performs a cystourethroscopy to examine the condition of the bladder and urethra, and then subsequently performs a UroLift transprostatic implant pro- cedure using three adjustable implants.

CPT code(s): ____________________________________________

(Part 1 is worth 20 points of your overall graded project.)

Part 2a Review each of the following procedures. Assign the CPT code(s). Add one or more modifiers, if necessary.

1. An established patient comes to the office complain- ing of migraine headaches. The physician performs an expanded problem-focused history and exam. The phy- sician’s medical decision making is of low complexity. During the office visit, the physician also removes a benign 0.5 cm lesion from the back of the patient’s left hand.

38166000 3

CPT code(s): ____________

________________________________________________________

2. Dr. Kline, a plastic surgeon, is ready to perform a sim- ple repair of a 2.0cm wound on the cheek of a 10 year old boy, but he is concerned about how the child might react. The boy has a neurological disorder that is triggered by anxiety and changes in his normal environment, and he has become combative at past office appointments. Although anesthesia is not typically used for a simple repair of a superficial wound, Dr. Kline has opted to administer the general anesthesia for this procedure. Dr. Kline proceeds with a simple repair of the child’s superfi- cial wound on his face.

CPT code(s): ____________

________________________________________________________

3. A surgeon performs a total abdominal hysterectomy with partial removal of the vagina, lymph node sampling, and removal of the ovary. The coder assigns code 58200-51. Is this code correct or incorrect? Why or why not?

________________________________________________________

________________________________________________________

Part 2b Review each of the following procedures. Assign the HCPCS code(s).

4. A patient weighing 252 pounds sustains a hip fracture. The physician prescribes a Group 2 standard single power wheelchair with a solid seat, solid back, and a sling.

HCPCS code(s): _______________

________________________________________________________

5. A patient comes to the emergency room complaining of a chronic migraine. The nurse administers a 1 unit injec- tion of onabotulinumtoxinA.

HCPCS code(s): _______________

________________________________________________________

Intermediate Medical Coding 4

6. A patient with chronic venous insufficiency comes to the doctor’s office complaining of leg pain. The physician prescribes two thigh-length gradient compression stock- ings, 45 mmHg each.

HCPCS code(s): _______________

________________________________________________________

(Part 2 is worth 60 points of your overall graded project: 30 points for Part 2a; 30 points for Part 2b.)

Part 3 Review the following coding scenario. Assign the CPT code(s) for only the wound repair. A patient comes to the emergency room after sustaining a 12.2-cm wound to the left side of her face. She was cut with a piece of glass during a physi- cal altercation with her husband. The physician performs a detailed history and examination. Medical decision making was of moderate complexity. The physician repairs the facial wound without difficulty; however, the wound requires exten- sive cleaning to remove the glass particles beforehand. The physician also repaired a superficial 2.5-cm wound to the left ear. Both wounds were closed using 4-0 Vicryl.

CPT code(s):__________________

___________________________________________________________

(Part 3 is worth 20 points of your overall graded project.)

Goal Your goal is to demonstrate your understanding of CPT and HCPCS and to assign codes accurately using both code sets.

GRADING CRITERIA Part 1 = 20 points

Part 2 = 60 points (2a = 30 points; 2b = 30 points)

Part 3 = 20 points

Health Care Timeline

 

 

ABC/123 Version X 1
Health Care Timeline

HCS/235 Version 10

1

University of Phoenix Material

Health Care Timeline

Complete the following timeline.

Select seven events that have helped shape health care as it is today. Write a 50- to 150-word summary per event that discusses the event and its effect on the health care industry. An example has been provided for you.

Health Care Throughout the Years
Date Event and Significance
1870-1889 Employers began to provide employee health care. Companies in several industries, including mining, lumber, and railroads, developed group industrial clinics with plans that prepaid doctors a fixed monthly fee to provide medical care to employees for industrial accidents and common illnesses.

Cite your sources below. For additional information on how to properly cite your sources, check out the Reference and Citation Generator resource in the Center for Writing Excellence.

Case Study 1

Case Study 1

A mother brings in her 16-month-old, Brittany, for treatment of an acute illness. During the history, the mother reports that her mother-in-law is concerned about the toddler’s development. Further questioning reveals the following:

  • Brittany was a term infant born vaginally with no intrapartum complications. Birth weight was 8 pounds 1 ounce and current weight is 26 pounds 9 ounces.
  • She was breastfed until 12 months of age and now drinks 24 ounces of whole milk and eats table foods daily.
  • Physical milestones are as follows: Rolled front to back at 6 months, developed pincer grasp at 11 months, crawled at 8 months, and began cruising at 10 months. She does not walk independently.
  • Social development includes mimicking adult behavior, four-word vocabulary (mama, dada, baba, and no), follows one-step commands, and quiets easily when comforted.

Case Study 2:

You see a 30-month-old named Brian for a well-child visit. His mother reports the following development:

  • Physical: Walks independently, runs, able to climb stairs alternating feet, makes a tower of nine cubes, and is able to button his pants.
  • Social: Follows one-step commands, uses one-word sentences, and has a vocabulary of approximately six words. He is resistant to nighttime and feeding routines, he has marked temper tantrums, and Mom states he does not calm when she tries to comfort him.

Case Study 3

Jose is a 36-month-old who presents for a preschool evaluation. His father reports the following development:

  • Physical: Walks, runs, and jumps independently, walks up stairs alternating feet, pedals a three-wheeler, scribbles, copies circles and squares, and is able to balance on one foot for 2 to 3 seconds.
  • Social: Recognizes three colors; speech is 75% understandable; uses three- to four-word sentences; talks about friends, favorite activities, and family; frequently engages in imitative play; has an imaginary friend; does stutter on occasion when excited or when intent on getting something said. Will typically repeat the first word in a sentence three to four times, but does not repeat syllables or consonants. This happens three to four times a week.

To prepare:

  • Review this week’s media presentations, as well as “Developmental Management of Infants” and “Developmental Management of Toddlers and Preschoolers” in the Burns et al. text.
  • Think about how physical, social, and cognitive development vary during infancy, toddlerhood, and the preschool years. Reflect on normal versus abnormal growth and development and consider the decision-making process of identifying and managing red flags of abnormal development.
  • Select one of the three case studies provided. Reflect on the patient information included in the case study and consider any developmental red flags.
  • Reflect on standardized screening tools, clinical guidelines, and management strategies that would be used to assess and manage the patient in your selected case study.

By Day 3

Post an explanation of any developmental red flags that presented in the case study you selected based on the stages of normal physical, social, and cognitive development for infants, toddlers, and preschoolers. Explain how you differentiated between normal and abnormal growth and development for this patient and identify which standardized screening tools, clinical guidelines, and management strategies you might use to assess and manage this patient and why.

Write up a referral request and include all key elements.

Write up a referral request and include all key elements.

As an NP and Ms. Perez primary care provider, you decide to refer her to Dr. Owens a dermatologist for evaluation and treatment regarding eczema unresponsive to treatment in the past six months.

1. Document your referral to Dr. Owens

2. Document the evaluation and recommendations for how Dr. Owens should deal with the referral and bill a referral code.

Written Paper (Microsoft Word doc): minimum 5 FULL PAGES, doubled spaced, words using 6th edition APA formatting

Community Assessment and Analysis Presentation

Community Assessment and Analysis Presentation

This assignment consists of both an interview and a PowerPoint (PPT) presentation.

Assessment/Interview

Select a community of interest in your region. Perform a physical assessment of the community.

1. Perform a direct assessment of a community of interest using the “Functional Health Patterns Community Assessment Guide.”

2. Interview a community health and public health provider regarding that person’s role and experiences within the community.

Interview Guidelines

Interviews can take place in-person, by phone, or by Skype.

Develop interview questions to gather information about the role of the provider in the community and the health issues faced by the chosen community.

Complete the “Provider Interview Acknowledgement Form” prior to conducting the interview. Submit this document separately in its respective drop box.

Compile key findings from the interview, including the interview questions used, and submit these with the presentation.

PowerPoint Presentation

Create a PowerPoint presentation of 15-20 slides (slide count does not include title and references slide) describing the chosen community interest.

Include the following in your presentation:

1. Description of community and community boundaries: the people and the geographic, geopolitical, financial, educational level; ethnic and phenomenological features of the community, as well as types of social interactions; common goals and interests; and barriers, and challenges, including any identified social determinates of health.

2. Summary of community assessment: (a) funding sources and (b) partnerships.

3. Summary of interview with community health/public health provider.

4. Identification of an issue that is lacking or an opportunity for health promotion.

5. A conclusion summarizing your key findings and a discussion of your impressions of the general health of the community.

While APA style, and thesis is required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA format ting guidelines.

Functional Health Patterns Community Assessment Guide

Functional Health Pattern (FHP) Template Directions:

This FHP template is to be used for organizing community assessment data in preparation for completion of the topic assignment. Address every bulleted statement in each section with data or rationale for deferral. You may also add additional bullet points if applicable to your community.

Value/Belief Pattern

Predominant ethnic and cultural groups along with beliefs related to health.

Predominant spiritual beliefs in the community that may influence health.

Availability of spiritual resources within or near the community (churches/chapels, synagogues, chaplains, Bible studies, sacraments, self-help groups, support groups, etc.).

Do the community members value health promotion measures? What is the evidence that they do or do not (e.g., involvement in education, fundraising events, etc.)?

What does the community value? How is this evident?

On what do the community members spend their money? Are funds adequate?

Health Perception/Management

Predominant health problems: Compare at least one health problem to a credible statistic (CDC, county, or state).

Immunization rates (age appropriate).

Appropriate death rates and causes, if applicable.

Prevention programs (dental, fire, fitness, safety, etc.): Does the community think these are sufficient?

Available health professionals, health resources within the community, and usage.

Common referrals to outside agencies.

Nutrition/Metabolic

Indicators of nutrient deficiencies.

Obesity rates or percentages: Compare to CDC statistics.

Affordability of food/available discounts or food programs and usage (e.g., WIC, food boxes, soup kitchens, meals-on-wheels, food stamps, senior discounts, employee discounts, etc.).

Availability of water (e.g., number and quality of drinking fountains).

Fast food and junk food accessibility (vending machines).

Community Assessment and Analysis Presentation

 

Community Assessment and Analysis Presentation

This assignment consists of both an interview and a PowerPoint (PPT) presentation.

Assessment/Interview

Select a community of interest in your region. Perform a physical assessment of the community.

1. Perform a direct assessment of a community of interest using the “Functional Health Patterns Community Assessment Guide.”

2. Interview a community health and public health provider regarding that person’s role and experiences within the community.

Interview Guidelines

Interviews can take place in-person, by phone, or by Skype.

Develop interview questions to gather information about the role of the provider in the community and the health issues faced by the chosen community.

Complete the “Provider Interview Acknowledgement Form” prior to conducting the interview. Submit this document separately in its respective drop box.

Compile key findings from the interview, including the interview questions used, and submit these with the presentation.

PowerPoint Presentation

Create a PowerPoint presentation of 15-20 slides (slide count does not include title and references slide) describing the chosen community interest.

Include the following in your presentation:

1. Description of community and community boundaries: the people and the geographic, geopolitical, financial, educational level; ethnic and phenomenological features of the community, as well as types of social interactions; common goals and interests; and barriers, and challenges, including any identified social determinates of health.

2. Summary of community assessment: (a) funding sources and (b) partnerships.

3. Summary of interview with community health/public health provider.

4. Identification of an issue that is lacking or an opportunity for health promotion.

5. A conclusion summarizing your key findings and a discussion of your impressions of the general health of the community.

While APA style, and thesis is required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA format ting guidelines.

Functional Health Patterns Community Assessment Guide

Functional Health Pattern (FHP) Template Directions:

This FHP template is to be used for organizing community assessment data in preparation for completion of the topic assignment. Address every bulleted statement in each section with data or rationale for deferral. You may also add additional bullet points if applicable to your community.

Value/Belief Pattern

Predominant ethnic and cultural groups along with beliefs related to health.

Predominant spiritual beliefs in the community that may influence health.

Availability of spiritual resources within or near the community (churches/chapels, synagogues, chaplains, Bible studies, sacraments, self-help groups, support groups, etc.).

Do the community members value health promotion measures? What is the evidence that they do or do not (e.g., involvement in education, fundraising events, etc.)?

What does the community value? How is this evident?

On what do the community members spend their money? Are funds adequate?

Health Perception/Management

Predominant health problems: Compare at least one health problem to a credible statistic (CDC, county, or state).

Immunization rates (age appropriate).

Appropriate death rates and causes, if applicable.

Prevention programs (dental, fire, fitness, safety, etc.): Does the community think these are sufficient?

Available health professionals, health resources within the community, and usage.

Common referrals to outside agencies.

Nutrition/Metabolic

Indicators of nutrient deficiencies.

Obesity rates or percentages: Compare to CDC statistics.

Affordability of food/available discounts or food programs and usage (e.g., WIC, food boxes, soup kitchens, meals-on-wheels, food stamps, senior discounts, employee discounts, etc.).

Availability of water (e.g., number and quality of drinking fountains).

Fast food and junk food accessibility (vending machines).

Provider Interview Acknowledgement Form

Student Name: __________________

Section & Faculty Name: _________________________________

Date of Interview: ________________

Provider Information

Provider Name :
Last First M.I.
Credentials: Title:
(i.e. MS, RN, etc.)
Organization:
Phone Number:
E-mail Address: