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MP 150 Introduction To Electronic Health Records

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MP 150 Introduction To Electronic Health Records Questions: 1.Do you believe that systems such as the CAC system will reduce the need for coders? Why or why not? 2.What problems might results from CAC? Provide examples. 3.I need to confirm the patient’s principal diagnosis for the chart I am coding. How should I do this? 4. The degree to which codes accurately reflect the patient’s diagnoses and procedures is: 5. I work at a substance abuse center. What system should I use to code diagnoses? 6. I need to code an ambulatory record but the procedure code I need is not in the CPT manual. How do I code it? Answers: Electronic Health Records Medical institutions have a lot of health records on different patients. These records hold the diagnosis and trends of a patient’s health and the treatment options provided by the doctor. With the advent improvement in technology, the medical field has embraced the computer assisted coding (CAC) that generates medical codes from medical documentation (Mag, 2010). The utilization of the CAC technique does not entirely eliminate the medical coding professionals. The primary benefit of using CAC is that it increases accuracy especially where the tasks required are repetitive or mundane. The human eye performs rather poorly in such circumstances. The coders are needed even if the CAC is implemented since the medical field continuously experiences change. The use of CAC in the medical institutions allow more coding to be done over a shorter period of time and less staff are employed hence they cut more costs. The medical field uses the ICD-10 code that updates the medical codes as well as describing the diagnoses and procedures in a detailed manner. The CAC does not manage to solve all the problems brought about by the ICD-10 transition. When the physicians provide the wrong information to the CAC systems, a huge problem ensues based on the Garbage In, Garbage Out concept. Some of the examples of the problems encountered are: – The software used may have difficulty differentiating E-codes and V-codes The codes are listed in numerical order. It is much more difficult to review and re-order in categories. Some of the code sections were highlighted as “x” instead of the 5thdigit which differentiates the obstetric codes from others. To confirm the patient’s principal diagnosis for coding for a chart one needs to review the discharge summary documents. Such a document shows all the procedures a patient went through before a final conclusion on the diagnosis was made. This document provides the correct information. The degree to which the codes accurately reflect the patient’s diagnosis and procedure is validity. For a person who works at a substance abuse center, the appropriate systems to use to code for the diagnosis is DSM-IV-TR. I need to code an ambulatory record but the procedure code is not in the CPT manual. Use the HCPS level 2 codes to code for it (CMS, 2015). In a nutshell, it is easy for one to code using the CAC systems as the systems present a myriad of advantages. It is much easier to perform data queries, it tends to decrease the coding costs, provides a coding evidence trail. The use of CAC systems provides consistency, productivity, and efficiency. The system uses the free text to record documentation using two techniques. The natural language processing technique reads narrative text and voice documents. It electronically records the key words while analyzing their context or use in different sections of the documentation. Another technique employed is the structured input. It allows the physician to generate records while picking out specific diagnostic phrases to which a code is generated. References CMS. (2015). ICD-10 Compliance. Official CMS Industry Resources for ICD-10 Transition, 1-32. Mag, H. (2010, January 29). Computer-Assisted coding: The secret weapon. Retrieved from The health Management Technology:

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