MCCG262 Professional Coder Practicum

MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing And Coding). As part of your internship with South Padre Medical Center, you are working under the supervision of the coding supervisor, Marla Kauffman. The clinic’s CDI Director, George Bowman, wants to better educate the physicians on the importance of accurate and complete medical records.  Therefore, George is planning on beginning a series of education sessions every month.

MCCG262 Professional Coder Practicum
He has asked Marla to prepare a presentation on proper documentation. Marla thinks that helping with this presentation would be a wonderful opportunity for you during your internship so that you can learn how to improve clinical documentation by identifying some key elements that are missing or unclear inpatient documentation. Marla’s plan for the presentation is to present some cases and examples where the coders did not have the information they needed to code.

MCCG262 Professional Coder Practicum
Marla has asked you to assist in preparing for this presentation by identifying any missing or unclear information from four patient records and drafting a PowerPoint presentation on your findings.

Because you are a new coder, Marla also thinks it would be helpful for you to research the importance of proper documentation and ways to ensure documentation is complete and accurate and then include information from your research findings into your PowerPoint presentation.

MCCG262 Professional Coder Practicum

Documentation Presentation

Course, Program, and Institutional Outcome(s) Assessed:

This assignment measures your ability to meet the follows outcome(s):

· Course outcome: Demonstrate competency and proficiency required for billing and coding operations in outpatient services.

· Course outcome: Evaluate patient records for accuracy and completeness, as defined by policy, regulations, and standards, and summarize finding to share with different stakeholders in the coding process.

· Program outcome: Evaluate the accuracy and completeness of the patient record as defined by policy, external regulations, and standards.

MCCG262 Professional Coder Practicum

· Institutional outcome – Information Literacy and Communication: Utilize appropriate current technology and resources to locate and evaluate information needed to accomplish a goal, and then communicate findings in visual, written, and/or oral formats.

Relevant Background Information:

Evaluating documentation for accuracy and completeness is part of a coding professional’s daily duties. It is essential that coders understand what components make up a complete and accurate medical record. As coders are reading through patients’ medical records to code them, they determine if the documentation is not complete or needs more clarity. In those instances, the coder will obtain the missing documentation or query the physician for further clarification.

MCCG262 Professional Coder Practicum Assignment Purpose:

This assignment asks you to review documentation in real patient medical records and specify if there is any missing or unclear documentation that the coder would need in order to assign the correct codes.

Assignment Directions:

As part of your internship with South Padre Medical Center, you are working under the supervision of the coding supervisor, Marla Kauffman. The clinic’s CDI Director, George Bowman, wants to better educate the physicians on the importance of accurate and complete medical records. Therefore, George is planning on beginning a series of education sessions every month. He has asked Marla to prepare a presentation on proper documentation.

Marla thinks that helping with this presentation would be a wonderful opportunity for you during your internship so that you can learn how to improve clinical documentation by identifying some key elements that are missing or unclear inpatient documentation. Marla’s plan for the presentation is to present some cases and examples where the coders did not have the information they needed to code. Marla has asked you to assist in preparing for this presentation by identifying any missing or unclear information from four patient records and drafting a PowerPoint presentation on your findings.

MCCG262 Professional Coder Practicum

Because you are a new coder, Marla also thinks it would be helpful for you to research the importance of proper documentation and ways to ensure documentation is complete and accurate and then include information from your research findings into your PowerPoint presentation.

Once you have reviewed the four patients’ medical records and completed your research, you will present your PowerPoint to Marla so she can determine how she wants to incorporate it into her presentation at the education session for the physicians.

Follow the steps below to complete this assignment:

MCCG262 Professional Coder Practicum Part 1: Research

1. Conduct research to find information on the importance of proper documentation and ways to ensure documentation is complete and accurate.

a. Make sure you find enough information to effectively explain proper documentation in your PowerPoint presentation.

b. Make sure your sources are authoritative and recent.

Part 2: Patient Record Review

2. Locate the following patient records in the AHIMA vLab Outpatient Clinic Cases:

a. 410057

b. 410092

c. 410198

d. 410296

3. Your coding supervisor has also provided you with a coding summary for each patient record. You may find these in the coding summary at the end of this document.

4. Review the patient records. For each patient record, identify if there is any missing or unclear information the coder would need.

Part 3: The PowerPoint Presentation

5. Gather the information from your sources and from your review of the four identified patient records. Create a PowerPoint presentation that achieves the following:

a. Provides examples from all four patient records of pieces of the medical records that are properly documented.

b. Provides examples from all four patient records of pieces of the medical records that do not have accurate or complete information.

c. Explains the importance of proper medical documentation.

d. Provides suggestions to ensure physician documentation is complete and accurate.

e. Is the right length to thoroughly cover all necessary information.

MCCG262 Professional Coder Practicum

Documentation Presentation

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