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Discuss the role of coding with the key features of an electronic health record (EHR) system and clinical document standards.Unit 10 Assignment:
Unit outcomes addressed in this Assignment:
Apply diagnostic and procedure codes according to current guidelines using common classification systems, taxonomies, nomenclatures and terminologiesIdentify the documentation needs that relate to quality coding practicesDiscuss the role of coding with the key features of an electronic health record (EHR) system and clinical document standards.Discuss the importance and relevance of Computer-Assisted Coding along with coding problems that may arise.
Course outcome(s) practiced in this unit:HI253-5: Appraise a health record for deficiencies needed for quality coding (Bloom’s Level 4)
AHIMA’s Professional Coding Approved Program (PCAP) Mapping:Domain I. Data Content, Structure & Standards (Information Governance)Subdomain I.A Classification Systems1. Apply diagnosis/procedure codes according to current guidelines (Bloom’s Level 3)Classification SystemsICD (ICD-9-CM, ICD-10, ICD-10-CM/PCS)TaxonomiesClinical Care Classification (CCC)NomenclaturesCPT, DSM, RxNormTerminologiesLOINC, SNOMED CTInstructions:
Part 1: Coding Scenario Worksheet (coding practice): Complete the coding scenarios worksheet indicated in Part 1 below by indicating the appropriate codes.
Part 2: Nuance Quantim Physician Query Activity: Please access the AHIMA’s Virtual Laboratories (VLabs) at http://academy.ahima.org/ website. Within the Virtual Lab (My Learning), go to the Virtual Lab applications and open the Nuance Quantim Encoder application and complete the Nuance Quantim #6 Activity on Physician Query activity with a passing score of 100% and appropriately identify the documentation needs that relate to quality coding practices. Answer the provided questions and submit a screen shot of your completed Physician Query activity in the Part 2 section of the Assignment Worksheet.Part 3: Electronic Health Record and Coding Systems:

 
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