[Solved] VI HTH

Assignment Prompt & Instructions

See attached

– ## UnitVIBlankPatientChart1.docx

– ## UnitVIWalterMoranPatientChart1.docx

– ## UnitVICaseStudyHTH.docx

– ## UnitVIHTH.pdf

**## UnitVIBlankPatientChart1.docx**

**Patient Name:**

**Age:**

**Gender:**

**Date of Admission:**

**Chief Complaint:**

**History of Present Illness (HPI):**

·

**Past Medical History (PMH):**

·

**Medications:**

·

**Physical Exam:**

·

**Assessment/Plan:**

·

**## UnitVIWalterMoranPatientChart1.docx**

**Patient Name:** Walter Moran

**Age:** 68

**Gender:** Male

**Date of Admission:** January 10, 2025

**Chief Complaint:** Shortness of breath

**History of Present Illness (HPI):**
"Patient reports feeling ‘winded’ for the past week. No known triggers. Has history of heart issues. Physical exam shows irregular breathing sounds."

**Past Medical History (PMH):**

· Hypertension

· Diabetes Mellitus (type unspecified)

· Heart Disease

**Medications:**

· Lisinopril 10mg, daily

· Metformin 500mg, twice daily

**Physical Exam:**

· General: Patient alert, cooperative.

· Cardiovascular: Heart rate irregular. No murmur noted.

· Respiratory: Slight wheezing on auscultation.

· Neurological: Normal exam.

**Assessment/Plan:**

· Assessment: "Patient likely has COPD. Start inhaler."

· Plan: "Follow up in two weeks."

**## UnitVICaseStudyHTH.docx**

Unit VI Case Study

This two-page case study measures your mastery of ULOs 2.3, 3.2, and 5.1.

As a future healthcare professional, your role includes making clinical documentation clear, accurate, and compliant with regulations. In this assignment, you will assume the role of a clinical documentation improvement specialist.

Your task for this case study is to review a patient’s chart and critique the patient notes. You will identify any issues in the documentation, including potential lack of clarity, missing details, and/or noncompliance.

Below are more detailed instructions for this case study assignment:

1. Download the
[patient chart for Walter Moran](https://online.columbiasouthern.edu/bbcswebdav/pid-17608227-dt-asiobject-rid-184699754_1/xid-184699754_1).

2. Examine the sections of the patient chart for any clinical documentation issues or areas where clarity is needed. Upload a two-page document of this case study:

3. One page documenting the issues in each chart section. If there are no issues in a section, be sure to explain why it is clear and without error.

4. One page on the importance of documentation accuracy in patient care. Include a real-life example of how inaccurate information can negatively impact care delivery.

5. Download and complete
[a new patient chart](https://online.columbiasouthern.edu/bbcswebdav/pid-17608227-dt-asiobject-rid-184699753_1/xid-184699753_1) for Walter Moran that corrects the issues found in the original document. Feel free to use hypothetical findings when missing specific details.

This completed case study will consent of two submissions:

· One-page document outlining the errors in the patient chart.

· New patient chart with the documentation corrections included.

Use course resources such as your textbook, unit articles, and study guides for guidance. Using outside references on the components of a detailed patient chart is suggested. If outside sources are used, please adhere to APA Style when creating citations and references for this assignment.

**## UnitVIHTH.pdf**

HTH 2305, Health Information Documentation Management 1

Course Learning Outcomes for Unit VI

At the end of this unit, you should be able to:

2. Discuss how medical coding impacts the health care revenue cycle.
2.3 Explain the importance of procedure coding as it relates to medical necessity.

3. Analyze medical records for accuracy and completeness.

3.2 Examine a patient’s medical chart for documentation errors.

5. Describe how accurate documentation improves health care delivery and patient outcomes.
5.1 Explain the benefits clinical documentation improvement has on patient care.

Required Unit Resources

Chapter 14: Procedure Coding (ULOs 2.3, 3.2, and 5.1)

Article: What is Clinical Documentation? (ULOs 2.3, 3.2, and 5.1)
The article defines clinical documentation and clinical documentation improvement (CDI). The article also
explains why CDI programs are needed. (8 pages).

Unit Lesson

Lesson: Procedure Medical Coding and Clinical Documentation Improvement (ULOs 2.3, 3.2,
and 5.1)

Introduction to Procedure Coding

In the last unit we learned about medical necessity and how diagnosis codes must match up with the patient
treatment plan. Diagnoses are classified using a medical coding system, and medical procedures and
services that are provided to patients are assigned a specific code as well. These procedure codes include
office visits, laboratory tests, radiology tests, home health care, or surgery. Distinguishing between inpatient
care and outpatient care is also important when it comes to procedure coding.

Outpatient procedure coding uses Current Procedural Terminology (CPT), the classification system used
exclusively for outpatient procedures and services, while inpatient procedure coding uses the International
Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS). In this unit we will
continue to learn about the importance of medical necessity and compliance through the use of accurate
procedure codes. This unit will also discuss initiatives such as Clinical Documentation Improvement (CDI) that
improve accuracy and successfully connect medical coding and medical billing.

Current Procedural Terminology (CPT)

The CPT manual is published by the American Medical Association (AMA) annually. This code system uses
five-digit code numbers (e.g., 57000 means colpotomy, with exploration) along with two-character modifiers
(LT, RT, -26), if needed. The CPT coding manual is broken up into six sections based on the type of service
provided:

1. Evaluation and Management (E/M)
2. Anesthesia
3. Surgery

UNIT VI STUDY GUIDE

Procedure Medical Coding and Clinical
Documentation Improvement

[https://www.aapc.com/resources/what-is-clinical-documentation?srsltid=AfmBOoqLEPFmfLe8GYvsCz5Iuksm7uXVXEcjlB7dHEfzupos0WaPcmww](https://www.aapc.com/resources/what-is-clinical-documentation?srsltid=AfmBOoqLEPFmfLe8GYvsCz5Iuksm7uXVXEcjlB7dHEfzupos0WaPcmww)

HTH 2305, Health Information Documentation Management 2

UNIT x STUDY GUIDE

Title

4. Radiology
5. Pathology and Laboratory
6. Medicine

Codes may be added, deleted, or descriptions of existing codes may be revised each October, which would
then go into effect on January 1st of the next year. Therefore, it is important that healthcare professionals use
the most current edition of the CPT manual and stay informed on any changes to maintain accurate coding. In
the previous unit we learned it is very important to accurately identify the status of a patient’s condition as this
is key for accurate coding and reimbursement. Procedure coding is no different.

Let's take the example of a patient being diagnosed with an acute condition versus a chronic condition. The
term acute means that there was a sudden onset of the condition the patient is experiencing. It typically runs
for a short time but can be very severe. A chronic condition, on the other hand, means that this health
concern has persisted over a long period of time and may come and go intermittently. This crucial difference
could influence the type of treatment that a physician orders for a patient, so attention to detail is key when
coding.

Health Common Procedure Coding System (HCPCS)

HCPCS codes are used to code for services, procedures, drugs, supplies, and products that can stand alone
from the classification of the CPT coding manual. The common term "Hick-Picks" includes, but is not limited
to, coding for walkers, wheelchairs, hearing aids, and other orthopedic equipment. These can comprise of
both temporary and permanent codes. This second-level coding system is comprised of alphanumeric codes
ranging from A through V (e.g., A0225 means ambulance, neonatal transport) and is used by many insurance
payers.

One important code block that is housed within HCPCS is the J-Code block, which has to do with the
administration of injectable drugs. Depending on the situation and medical setting, multiple drugs could be
used to stabilize or treat a patient, so understanding how to code these injections are important. Healthcare
professionals tasked with coding drug injections must also take into account the dosage of certain drugs.

For example, a cancer patient receiving chemotherapy might require an infusion of a drug like bevacizumab
(HCPCS code J9035, injection, 10 mg). If a doctor orders 30 mg of this drug to be administered to the patient,
the medical coder will need to know to produce this code three times. HIM staff should document the total
dosage administered, apply the correct HCPCS code by verifying the units of drugs used.

Clinical Documentation Improvement

Another important aspect of the healthcare revenue cycle is the role that clinical documentation improvement
(CDI) plays in health information management. Clinical documentation improvement, also known as clinical
documentation integrity, is a tool that ensures high-quality patient care, compliance, and proper
reimbursement. Let’s explore medical documentation areas that require validation to achieve these goals.

First, patient information must be verified, including the patient’s name, age, date of birth, medical record
number, and other demographic details such as gender, race, and preferred language. This ensures records
are tied to the correct patient and supports personalized care.

Any history of present illness, or HPI, must be thorough and specific, detailing the onset, duration, location,
severity, modifying factors, and associated symptoms. Specificity is vital. Ambiguous terms or phrases such
as "feeling bad" or "heart issues" should be avoided in favor of precise descriptions that give a
comprehensive overview of the patient’s situation. This level of detail improves the accuracy of the record and
facilitates better diagnosis and treatment planning.

Past medical, surgical, and family histories must include relevant details, such as specific conditions, surgical
dates, and family risks when applicable. This information offers context for understanding the patient’s overall
health, providing valuable insights into hereditary risks or predispositions.

Medication information should also be included in documentation. All medications should be listed along with
their dose, route, frequency, and the reason for prescription. Abbreviations like “q.d.” should be replaced with

HTH 2305, Health Information Documentation Management 3

UNIT x STUDY GUIDE

Title

clear terms like “daily” to avoid potential misinterpretation. Detailed documentation supports continuity of care
and also reduces the risk of medication errors.

In the physical exam section, vital signs must always be recorded, as they provide baseline data for
assessing the patient’s condition. This section should also cover all relevant systems (cardiovascular,
respiratory, and neurological) in a thorough manner.

The assessment and plan section ties everything together. Diagnoses must be specific and supported by
documented evidence, such as test results or clinical findings. The plan should outline the next steps clearly,
including any diagnostic tests or labs needed to confirm the diagnosis. It should also include detailed
treatment instructions, specifying medication types, dosages, and frequency (if not included elsewhere in the
patient chart), along with clear follow-up instructions that indicate when and with whom the patient should
follow up.

Diagnoses and procedures must be coded with sufficient documentation to justify services. Incomplete or
conflicting information in the chart can lead to coding errors, which may result in claim denials. Proper
documentation ensures that the medical record supports accurate billing and reimbursement.

Compliance with documentation standards is key. Language should remain professional and follow etiquette
guidelines to ensure the record is clear and actionable. By focusing on these areas, we can ensure that
clinical documentation supports effective care, accurate billing, and regulatory compliance.

Conclusion

Our chapter readings for this unit cover important details related to the standard procedure code sets used for
coding services and procedures. CPT and HCPCS are valuable classification systems and all HIM
professionals should have a basic knowledge of their purpose and function. Medical coders and
reimbursement specialists should use updated coding data to avoid potential reimbursement issues such as
partial payments, denials, or rejections of insurance claims. This is why CDI plays such an instrumental role
as a bridge between coding and billing. If questions arise from clinical documentation, the proper course of
action is to seek clarification from a physician, lead coder, or the insurance company.

References

AAPC. (2024, January 29). What is clinical documentation. https://www.aapc.com/resources/what-is-clinical-

documentation?srsltid=AfmBOoqLEPFmfLe8GYvsCz5Iuksm7uXVXEcjlB7dHEfzupos0WaPcmww

French, L. L., & Turner, L. H. (2024). Administrative medical assisting (9th ed.). Cengage.

**## UnitVIHTH.pdf**

HTH 2305, Health Information Documentation Management 1

Course Learning Outcomes for Unit VI

At the end of this unit, you should be able to:

2. Discuss how medical coding impacts the health care revenue cycle.
2.3 Explain the importance of procedure coding as it relates to medical necessity.

3. Analyze medical records for accuracy and completeness.

3.2 Examine a patient’s medical chart for documentation errors.

5. Describe how accurate documentation improves health care delivery and patient outcomes.
5.1 Explain the benefits clinical documentation improvement has on patient care.

Required Unit Resources

Chapter 14: Procedure Coding (ULOs 2.3, 3.2, and 5.1)

Article: What is Clinical Documentation? (ULOs 2.3, 3.2, and 5.1)
The article defines clinical documentation and clinical documentation improvement (CDI). The article also
explains why CDI programs are needed. (8 pages).

Unit Lesson

Lesson: Procedure Medical Coding and Clinical Documentation Improvement (ULOs 2.3, 3.2,
and 5.1)

Introduction to Procedure Coding

In the last unit we learned about medical necessity and how diagnosis codes must match up with the patient
treatment plan. Diagnoses are classified using a medical coding system, and medical procedures and
services that are provided to patients are assigned a specific code as well. These procedure codes include
office visits, laboratory tests, radiology tests, home health care, or surgery. Distinguishing between inpatient
care and outpatient care is also important when it comes to procedure coding.

Outpatient procedure coding uses Current Procedural Terminology (CPT), the classification system used
exclusively for outpatient procedures and services, while inpatient procedure coding uses the International
Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS). In this unit we will
continue to learn about the importance of medical necessity and compliance through the use of accurate
procedure codes. This unit will also discuss initiatives such as Clinical Documentation Improvement (CDI) that
improve accuracy and successfully connect medical coding and medical billing.

Current Procedural Terminology (CPT)

The CPT manual is published by the American Medical Association (AMA) annually. This code system uses
five-digit code numbers (e.g., 57000 means colpotomy, with exploration) along with two-character modifiers
(LT, RT, -26), if needed. The CPT coding manual is broken up into six sections based on the type of service
provided:

1. Evaluation and Management (E/M)
2. Anesthesia
3. Surgery

UNIT VI STUDY GUIDE

Procedure Medical Coding and Clinical
Documentation Improvement

[https://www.aapc.com/resources/what-is-clinical-documentation?srsltid=AfmBOoqLEPFmfLe8GYvsCz5Iuksm7uXVXEcjlB7dHEfzupos0WaPcmww](https://www.aapc.com/resources/what-is-clinical-documentation?srsltid=AfmBOoqLEPFmfLe8GYvsCz5Iuksm7uXVXEcjlB7dHEfzupos0WaPcmww)

HTH 2305, Health Information Documentation Management 2

UNIT x STUDY GUIDE

Title

4. Radiology
5. Pathology and Laboratory
6. Medicine

Codes may be added, deleted, or descriptions of existing codes may be revised each October, which would
then go into effect on January 1st of the next year. Therefore, it is important that healthcare professionals use
the most current edition of the CPT manual and stay informed on any changes to maintain accurate coding. In
the previous unit we learned it is very important to accurately identify the status of a patient’s condition as this
is key for accurate coding and reimbursement. Procedure coding is no different.

Let's take the example of a patient being diagnosed with an acute condition versus a chronic condition. The
term acute means that there was a sudden onset of the condition the patient is experiencing. It typically runs
for a short time but can be very severe. A chronic condition, on the other hand, means that this health
concern has persisted over a long period of time and may come and go intermittently. This crucial difference
could influence the type of treatment that a physician orders for a patient, so attention to detail is key when
coding.

Health Common Procedure Coding System (HCPCS)

HCPCS codes are used to code for services, procedures, drugs, supplies, and products that can stand alone
from the classification of the CPT coding manual. The common term "Hick-Picks" includes, but is not limited
to, coding for walkers, wheelchairs, hearing aids, and other orthopedic equipment. These can comprise of
both temporary and permanent codes. This second-level coding system is comprised of alphanumeric codes
ranging from A through V (e.g., A0225 means ambulance, neonatal transport) and is used by many insurance
payers.

One important code block that is housed within HCPCS is the J-Code block, which has to do with the
administration of injectable drugs. Depending on the situation and medical setting, multiple drugs could be
used to stabilize or treat a patient, so understanding how to code these injections are important. Healthcare
professionals tasked with coding drug injections must also take into account the dosage of certain drugs.

For example, a cancer patient receiving chemotherapy might require an infusion of a drug like bevacizumab
(HCPCS code J9035, injection, 10 mg). If a doctor orders 30 mg of this drug to be administered to the patient,
the medical coder will need to know to produce this code three times. HIM staff should document the total
dosage administered, apply the correct HCPCS code by verifying the units of drugs used.

Clinical Documentation Improvement

Another important aspect of the healthcare revenue cycle is the role that clinical documentation improvement
(CDI) plays in health information management. Clinical documentation improvement, also known as clinical
documentation integrity, is a tool that ensures high-quality patient care, compliance, and proper
reimbursement. Let’s explore medical documentation areas that require validation to achieve these goals.

First, patient information must be verified, including the patient’s name, age, date of birth, medical record
number, and other demographic details such as gender, race, and preferred language. This ensures records
are tied to the correct patient and supports personalized care.

Any history of present illness, or HPI, must be thorough and specific, detailing the onset, duration, location,
severity, modifying factors, and associated symptoms. Specificity is vital. Ambiguous terms or phrases such
as "feeling bad" or "heart issues" should be avoided in favor of precise descriptions that give a
comprehensive overview of the patient’s situation. This level of detail improves the accuracy of the record and
facilitates better diagnosis and treatment planning.

Past medical, surgical, and family histories must include relevant details, such as specific conditions, surgical
dates, and family risks when applicable. This information offers context for understanding the patient’s overall
health, providing valuable insights into hereditary risks or predispositions.

Medication information should also be included in documentation. All medications should be listed along with
their dose, route, frequency, and the reason for prescription. Abbreviations like “q.d.” should be replaced with

HTH 2305, Health Information Documentation Management 3

UNIT x STUDY GUIDE

Title

clear terms like “daily” to avoid potential misinterpretation. Detailed documentation supports continuity of care
and also reduces the risk of medication errors.

In the physical exam section, vital signs must always be recorded, as they provide baseline data for
assessing the patient’s condition. This section should also cover all relevant systems (cardiovascular,
respiratory, and neurological) in a thorough manner.

The assessment and plan section ties everything together. Diagnoses must be specific and supported by
documented evidence, such as test results or clinical findings. The plan should outline the next steps clearly,
including any diagnostic tests or labs needed to confirm the diagnosis. It should also include detailed
treatment instructions, specifying medication types, dosages, and frequency (if not included elsewhere in the
patient chart), along with clear follow-up instructions that indicate when and with whom the patient should
follow up.

Diagnoses and procedures must be coded with sufficient documentation to justify services. Incomplete or
conflicting information in the chart can lead to coding errors, which may result in claim denials. Proper
documentation ensures that the medical record supports accurate billing and reimbursement.

Compliance with documentation standards is key. Language should remain professional and follow etiquette
guidelines to ensure the record is clear and actionable. By focusing on these areas, we can ensure that
clinical documentation supports effective care, accurate billing, and regulatory compliance.

Conclusion

Our chapter readings for this unit cover important details related to the standard procedure code sets used for
coding services and procedures. CPT and HCPCS are valuable classification systems and all HIM
professionals should have a basic knowledge of their purpose and function. Medical coders and
reimbursement specialists should use updated coding data to avoid potential reimbursement issues such as
partial payments, denials, or rejections of insurance claims. This is why CDI plays such an instrumental role
as a bridge between coding and billing. If questions arise from clinical documentation, the proper course of
action is to seek clarification from a physician, lead coder, or the insurance company.

References

AAPC. (2024, January 29). What is clinical documentation. https://www.aapc.com/resources/what-is-clinical-

documentation?srsltid=AfmBOoqLEPFmfLe8GYvsCz5Iuksm7uXVXEcjlB7dHEfzupos0WaPcmww

French, L. L., & Turner, L. H. (2024). Administrative medical assisting (9th ed.). Cengage.

**## UnitVIBlankPatientChart1.docx**

**Patient Name:**

**Age:**

**Gender:**

**Date of Admission:**

**Chief Complaint:**

**History of Present Illness (HPI):**

·

**Past Medical History (PMH):**

·

**Medications:**

·

**Physical Exam:**

·

**Assessment/Plan:**

·

**## UnitVIWalterMoranPatientChart1.docx**

**Patient Name:** Walter Moran

**Age:** 68

**Gender:** Male

**Date of Admission:** January 10, 2025

**Chief Complaint:** Shortness of breath

**History of Present Illness (HPI):**
"Patient reports feeling ‘winded’ for the past week. No known triggers. Has history of heart issues. Physical exam shows irregular breathing sounds."

**Past Medical History (PMH):**

· Hypertension

· Diabetes Mellitus (type unspecified)

· Heart Disease

**Medications:**

· Lisinopril 10mg, daily

· Metformin 500mg, twice daily

**Physical Exam:**

· General: Patient alert, cooperative.

· Cardiovascular: Heart rate irregular. No murmur noted.

· Respiratory: Slight wheezing on auscultation.

· Neurological: Normal exam.

**Assessment/Plan:**

· Assessment: "Patient likely has COPD. Start inhaler."

· Plan: "Follow up in two weeks."

**## UnitVICaseStudyHTH.docx**

Unit VI Case Study

This two-page case study measures your mastery of ULOs 2.3, 3.2, and 5.1.

As a future healthcare professional, your role includes making clinical documentation clear, accurate, and compliant with regulations. In this assignment, you will assume the role of a clinical documentation improvement specialist.

Your task for this case study is to review a patient’s chart and critique the patient notes. You will identify any issues in the documentation, including potential lack of clarity, missing details, and/or noncompliance.

Below are more detailed instructions for this case study assignment:

1. Download the
[patient chart for Walter Moran](https://online.columbiasouthern.edu/bbcswebdav/pid-17608227-dt-asiobject-rid-184699754_1/xid-184699754_1).

2. Examine the sections of the patient chart for any clinical documentation issues or areas where clarity is needed. Upload a two-page document of this case study:

3. One page documenting the issues in each chart section. If there are no issues in a section, be sure to explain why it is clear and without error.

4. One page on the importance of documentation accuracy in patient care. Include a real-life example of how inaccurate information can negatively impact care delivery.

5. Download and complete
[a new patient chart](https://online.columbiasouthern.edu/bbcswebdav/pid-17608227-dt-asiobject-rid-184699753_1/xid-184699753_1) for Walter Moran that corrects the issues found in the original document. Feel free to use hypothetical findings when missing specific details.

This completed case study will consent of two submissions:

· One-page document outlining the errors in the patient chart.

· New patient chart with the documentation corrections included.

Use course resources such as your textbook, unit articles, and study guides for guidance. Using outside references on the components of a detailed patient chart is suggested. If outside sources are used, please adhere to APA Style when creating citations and references for this assignment.

**## UnitVIHTH.pdf**

HTH 2305, Health Information Documentation Management 1

Course Learning Outcomes for Unit VI

At the end of this unit, you should be able to:

2. Discuss how medical coding impacts the health care revenue cycle.
2.3 Explain the importance of procedure coding as it relates to medical necessity.

3. Analyze medical records for accuracy and completeness.

3.2 Examine a patient’s medical chart for documentation errors.

5. Describe how accurate documentation improves health care delivery and patient outcomes.
5.1 Explain the benefits clinical documentation improvement has on patient care.

Required Unit Resources

Chapter 14: Procedure Coding (ULOs 2.3, 3.2, and 5.1)

Article: What is Clinical Documentation? (ULOs 2.3, 3.2, and 5.1)
The article defines clinical documentation and clinical documentation improvement (CDI). The article also
explains why CDI programs are needed. (8 pages).

Unit Lesson

Lesson: Procedure Medical Coding and Clinical Documentation Improvement (ULOs 2.3, 3.2,
and 5.1)

Introduction to Procedure Coding

In the last unit we learned about medical necessity and how diagnosis codes must match up with the patient
treatment plan. Diagnoses are classified using a medical coding system, and medical procedures and
services that are provided to patients are assigned a specific code as well. These procedure codes include
office visits, laboratory tests, radiology tests, home health care, or surgery. Distinguishing between inpatient
care and outpatient care is also important when it comes to procedure coding.

Outpatient procedure coding uses Current Procedural Terminology (CPT), the classification system used
exclusively for outpatient procedures and services, while inpatient procedure coding uses the International
Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS). In this unit we will
continue to learn about the importance of medical necessity and compliance through the use of accurate
procedure codes. This unit will also discuss initiatives such as Clinical Documentation Improvement (CDI) that
improve accuracy and successfully connect medical coding and medical billing.

Current Procedural Terminology (CPT)

The CPT manual is published by the American Medical Association (AMA) annually. This code system uses
five-digit code numbers (e.g., 57000 means colpotomy, with exploration) along with two-character modifiers
(LT, RT, -26), if needed. The CPT coding manual is broken up into six sections based on the type of service
provided:

1. Evaluation and Management (E/M)
2. Anesthesia
3. Surgery

UNIT VI STUDY GUIDE

Procedure Medical Coding and Clinical
Documentation Improvement

[https://www.aapc.com/resources/what-is-clinical-documentation?srsltid=AfmBOoqLEPFmfLe8GYvsCz5Iuksm7uXVXEcjlB7dHEfzupos0WaPcmww](https://www.aapc.com/resources/what-is-clinical-documentation?srsltid=AfmBOoqLEPFmfLe8GYvsCz5Iuksm7uXVXEcjlB7dHEfzupos0WaPcmww)

HTH 2305, Health Information Documentation Management 2

UNIT x STUDY GUIDE

Title

4. Radiology
5. Pathology and Laboratory
6. Medicine

Codes may be added, deleted, or descriptions of existing codes may be revised each October, which would
then go into effect on January 1st of the next year. Therefore, it is important that healthcare professionals use
the most current edition of the CPT manual and stay informed on any changes to maintain accurate coding. In
the previous unit we learned it is very important to accurately identify the status of a patient’s condition as this
is key for accurate coding and reimbursement. Procedure coding is no different.

Let's take the example of a patient being diagnosed with an acute condition versus a chronic condition. The
term acute means that there was a sudden onset of the condition the patient is experiencing. It typically runs
for a short time but can be very severe. A chronic condition, on the other hand, means that this health
concern has persisted over a long period of time and may come and go intermittently. This crucial difference
could influence the type of treatment that a physician orders for a patient, so attention to detail is key when
coding.

Health Common Procedure Coding System (HCPCS)

HCPCS codes are used to code for services, procedures, drugs, supplies, and products that can stand alone
from the classification of the CPT coding manual. The common term "Hick-Picks" includes, but is not limited
to, coding for walkers, wheelchairs, hearing aids, and other orthopedic equipment. These can comprise of
both temporary and permanent codes. This second-level coding system is comprised of alphanumeric codes
ranging from A through V (e.g., A0225 means ambulance, neonatal transport) and is used by many insurance
payers.

One important code block that is housed within HCPCS is the J-Code block, which has to do with the
administration of injectable drugs. Depending on the situation and medical setting, multiple drugs could be
used to stabilize or treat a patient, so understanding how to code these injections are important. Healthcare
professionals tasked with coding drug injections must also take into account the dosage of certain drugs.

For example, a cancer patient receiving chemotherapy might require an infusion of a drug like bevacizumab
(HCPCS code J9035, injection, 10 mg). If a doctor orders 30 mg of this drug to be administered to the patient,
the medical coder will need to know to produce this code three times. HIM staff should document the total
dosage administered, apply the correct HCPCS code by verifying the units of drugs used.

Clinical Documentation Improvement

Another important aspect of the healthcare revenue cycle is the role that clinical documentation improvement
(CDI) plays in health information management. Clinical documentation improvement, also known as clinical
documentation integrity, is a tool that ensures high-quality patient care, compliance, and proper
reimbursement. Let’s explore medical documentation areas that require validation to achieve these goals.

First, patient information must be verified, including the patient’s name, age, date of birth, medical record
number, and other demographic details such as gender, race, and preferred language. This ensures records
are tied to the correct patient and supports personalized care.

Any history of present illness, or HPI, must be thorough and specific, detailing the onset, duration, location,
severity, modifying factors, and associated symptoms. Specificity is vital. Ambiguous terms or phrases such
as "feeling bad" or "heart issues" should be avoided in favor of precise descriptions that give a
comprehensive overview of the patient’s situation. This level of detail improves the accuracy of the record and
facilitates better diagnosis and treatment planning.

Past medical, surgical, and family histories must include relevant details, such as specific conditions, surgical
dates, and family risks when applicable. This information offers context for understanding the patient’s overall
health, providing valuable insights into hereditary risks or predispositions.

Medication information should also be included in documentation. All medications should be listed along with
their dose, route, frequency, and the reason for prescription. Abbreviations like “q.d.” should be replaced with

HTH 2305, Health Information Documentation Management 3

UNIT x STUDY GUIDE

Title

clear terms like “daily” to avoid potential misinterpretation. Detailed documentation supports continuity of care
and also reduces the risk of medication errors.

In the physical exam section, vital signs must always be recorded, as they provide baseline data for
assessing the patient’s condition. This section should also cover all relevant systems (cardiovascular,
respiratory, and neurological) in a thorough manner.

The assessment and plan section ties everything together. Diagnoses must be specific and supported by
documented evidence, such as test results or clinical findings. The plan should outline the next steps clearly,
including any diagnostic tests or labs needed to confirm the diagnosis. It should also include detailed
treatment instructions, specifying medication types, dosages, and frequency (if not included elsewhere in the
patient chart), along with clear follow-up instructions that indicate when and with whom the patient should
follow up.

Diagnoses and procedures must be coded with sufficient documentation to justify services. Incomplete or
conflicting information in the chart can lead to coding errors, which may result in claim denials. Proper
documentation ensures that the medical record supports accurate billing and reimbursement.

Compliance with documentation standards is key. Language should remain professional and follow etiquette
guidelines to ensure the record is clear and actionable. By focusing on these areas, we can ensure that
clinical documentation supports effective care, accurate billing, and regulatory compliance.

Conclusion

Our chapter readings for this unit cover important details related to the standard procedure code sets used for
coding services and procedures. CPT and HCPCS are valuable classification systems and all HIM
professionals should have a basic knowledge of their purpose and function. Medical coders and
reimbursement specialists should use updated coding data to avoid potential reimbursement issues such as
partial payments, denials, or rejections of insurance claims. This is why CDI plays such an instrumental role
as a bridge between coding and billing. If questions arise from clinical documentation, the proper course of
action is to seek clarification from a physician, lead coder, or the insurance company.

References

AAPC. (2024, January 29). What is clinical documentation. https://www.aapc.com/resources/what-is-clinical-

documentation?srsltid=AfmBOoqLEPFmfLe8GYvsCz5Iuksm7uXVXEcjlB7dHEfzupos0WaPcmww

French, L. L., & Turner, L. H. (2024). Administrative medical assisting (9th ed.). Cengage.

**## UnitVIBlankPatientChart1.docx**

**Patient Name:**

**Age:**

**Gender:**

**Date of Admission:**

**Chief Complaint:**

**History of Present Illness (HPI):**

·

**Past Medical History (PMH):**

·

**Medications:**

·

**Physical Exam:**

·

**Assessment/Plan:**

·

**## UnitVIWalterMoranPatientChart1.docx**

**Patient Name:** Walter Moran

**Age:** 68

**Gender:** Male

**Date of Admission:** January 10, 2025

**Chief Complaint:** Shortness of breath

**History of Present Illness (HPI):**
"Patient reports feeling ‘winded’ for the past week. No known triggers. Has history of heart issues. Physical exam shows irregular breathing sounds."

**Past Medical History (PMH):**

· Hypertension

· Diabetes Mellitus (type unspecified)

· Heart Disease

**Medications:**

· Lisinopril 10mg, daily

· Metformin 500mg, twice daily

**Physical Exam:**

· General: Patient alert, cooperative.

· Cardiovascular: Heart rate irregular. No murmur noted.

· Respiratory: Slight wheezing on auscultation.

· Neurological: Normal exam.

**Assessment/Plan:**

· Assessment: "Patient likely has COPD. Start inhaler."

· Plan: "Follow up in two weeks."

**## UnitVICaseStudyHTH.docx**

Unit VI Case Study

This two-page case study measures your mastery of ULOs 2.3, 3.2, and 5.1.

As a future healthcare professional, your role includes making clinical documentation clear, accurate, and compliant with regulations. In this assignment, you will assume the role of a clinical documentation improvement specialist.

Your task for this case study is to review a patient’s chart and critique the patient notes. You will identify any issues in the documentation, including potential lack of clarity, missing details, and/or noncompliance.

Below are more detailed instructions for this case study assignment:

1. Download the
[patient chart for Walter Moran](https://online.columbiasouthern.edu/bbcswebdav/pid-17608227-dt-asiobject-rid-184699754_1/xid-184699754_1).

2. Examine the sections of the patient chart for any clinical documentation issues or areas where clarity is needed. Upload a two-page document of this case study:

3. One page documenting the issues in each chart section. If there are no issues in a section, be sure to explain why it is clear and without error.

4. One page on the importance of documentation accuracy in patient care. Include a real-life example of how inaccurate information can negatively impact care delivery.

5. Download and complete
[a new patient chart](https://online.columbiasouthern.edu/bbcswebdav/pid-17608227-dt-asiobject-rid-184699753_1/xid-184699753_1) for Walter Moran that corrects the issues found in the original document. Feel free to use hypothetical findings when missing specific details.

This completed case study will consent of two submissions:

· One-page document outlining the errors in the patient chart.

· New patient chart with the documentation corrections included.

Use course resources such as your textbook, unit articles, and study guides for guidance. Using outside references on the components of a detailed patient chart is suggested. If outside sources are used, please adhere to APA Style when creating citations and references for this assignment.

**## UnitVIHTH.pdf**

HTH 2305, Health Information Documentation Management 1

Course Learning Outcomes for Unit VI

At the end of this unit, you should be able to:

2. Discuss how medical coding impacts the health care revenue cycle.
2.3 Explain the importance of procedure coding as it relates to medical necessity.

3. Analyze medical records for accuracy and completeness.

3.2 Examine a patient’s medical chart for documentation errors.

5. Describe how accurate documentation improves health care delivery and patient outcomes.
5.1 Explain the benefits clinical documentation improvement has on patient care.

Required Unit Resources

Chapter 14: Procedure Coding (ULOs 2.3, 3.2, and 5.1)

Article: What is Clinical Documentation? (ULOs 2.3, 3.2, and 5.1)
The article defines clinical documentation and clinical documentation improvement (CDI). The article also
explains why CDI programs are needed. (8 pages).

Unit Lesson

Lesson: Procedure Medical Coding and Clinical Documentation Improvement (ULOs 2.3, 3.2,
and 5.1)

Introduction to Procedure Coding

In the last unit we learned about medical necessity and how diagnosis codes must match up with the patient
treatment plan. Diagnoses are classified using a medical coding system, and medical procedures and
services that are provided to patients are assigned a specific code as well. These procedure codes include
office visits, laboratory tests, radiology tests, home health care, or surgery. Distinguishing between inpatient
care and outpatient care is also important when it comes to procedure coding.

Outpatient procedure coding uses Current Procedural Terminology (CPT), the classification system used
exclusively for outpatient procedures and services, while inpatient procedure coding uses the International
Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS). In this unit we will
continue to learn about the importance of medical necessity and compliance through the use of accurate
procedure codes. This unit will also discuss initiatives such as Clinical Documentation Improvement (CDI) that
improve accuracy and successfully connect medical coding and medical billing.

Current Procedural Terminology (CPT)

The CPT manual is published by the American Medical Association (AMA) annually. This code system uses
five-digit code numbers (e.g., 57000 means colpotomy, with exploration) along with two-character modifiers
(LT, RT, -26), if needed. The CPT coding manual is broken up into six sections based on the type of service
provided:

1. Evaluation and Management (E/M)
2. Anesthesia
3. Surgery

UNIT VI STUDY GUIDE

Procedure Medical Coding and Clinical
Documentation Improvement

[https://www.aapc.com/resources/what-is-clinical-documentation?srsltid=AfmBOoqLEPFmfLe8GYvsCz5Iuksm7uXVXEcjlB7dHEfzupos0WaPcmww](https://www.aapc.com/resources/what-is-clinical-documentation?srsltid=AfmBOoqLEPFmfLe8GYvsCz5Iuksm7uXVXEcjlB7dHEfzupos0WaPcmww)

HTH 2305, Health Information Documentation Management 2

UNIT x STUDY GUIDE

Title

4. Radiology
5. Pathology and Laboratory
6. Medicine

Codes may be added, deleted, or descriptions of existing codes may be revised each October, which would
then go into effect on January 1st of the next year. Therefore, it is important that healthcare professionals use
the most current edition of the CPT manual and stay informed on any changes to maintain accurate coding. In
the previous unit we learned it is very important to accurately identify the status of a patient’s condition as this
is key for accurate coding and reimbursement. Procedure coding is no different.

Let's take the example of a patient being diagnosed with an acute condition versus a chronic condition. The
term acute means that there was a sudden onset of the condition the patient is experiencing. It typically runs
for a short time but can be very severe. A chronic condition, on the other hand, means that this health
concern has persisted over a long period of time and may come and go intermittently. This crucial difference
could influence the type of treatment that a physician orders for a patient, so attention to detail is key when
coding.

Health Common Procedure Coding System (HCPCS)

HCPCS codes are used to code for services, procedures, drugs, supplies, and products that can stand alone
from the classification of the CPT coding manual. The common term "Hick-Picks" includes, but is not limited
to, coding for walkers, wheelchairs, hearing aids, and other orthopedic equipment. These can comprise of
both temporary and permanent codes. This second-level coding system is comprised of alphanumeric codes
ranging from A through V (e.g., A0225 means ambulance, neonatal transport) and is used by many insurance
payers.

One important code block that is housed within HCPCS is the J-Code block, which has to do with the
administration of injectable drugs. Depending on the situation and medical setting, multiple drugs could be
used to stabilize or treat a patient, so understanding how to code these injections are important. Healthcare
professionals tasked with coding drug injections must also take into account the dosage of certain drugs.

For example, a cancer patient receiving chemotherapy might require an infusion of a drug like bevacizumab
(HCPCS code J9035, injection, 10 mg). If a doctor orders 30 mg of this drug to be administered to the patient,
the medical coder will need to know to produce this code three times. HIM staff should document the total
dosage administered, apply the correct HCPCS code by verifying the units of drugs used.

Clinical Documentation Improvement

Another important aspect of the healthcare revenue cycle is the role that clinical documentation improvement
(CDI) plays in health information management. Clinical documentation improvement, also known as clinical
documentation integrity, is a tool that ensures high-quality patient care, compliance, and proper
reimbursement. Let’s explore medical documentation areas that require validation to achieve these goals.

First, patient information must be verified, including the patient’s name, age, date of birth, medical record
number, and other demographic details such as gender, race, and preferred language. This ensures records
are tied to the correct patient and supports personalized care.

Any history of present illness, or HPI, must be thorough and specific, detailing the onset, duration, location,
severity, modifying factors, and associated symptoms. Specificity is vital. Ambiguous terms or phrases such
as "feeling bad" or "heart issues" should be avoided in favor of precise descriptions that give a
comprehensive overview of the patient’s situation. This level of detail improves the accuracy of the record and
facilitates better diagnosis and treatment planning.

Past medical, surgical, and family histories must include relevant details, such as specific conditions, surgical
dates, and family risks when applicable. This information offers context for understanding the patient’s overall
health, providing valuable insights into hereditary risks or predispositions.

Medication information should also be included in documentation. All medications should be listed along with
their dose, route, frequency, and the reason for prescription. Abbreviations like “q.d.” should be replaced with

HTH 2305, Health Information Documentation Management 3

UNIT x STUDY GUIDE

Title

clear terms like “daily” to avoid potential misinterpretation. Detailed documentation supports continuity of care
and also reduces the risk of medication errors.

In the physical exam section, vital signs must always be recorded, as they provide baseline data for
assessing the patient’s condition. This section should also cover all relevant systems (cardiovascular,
respiratory, and neurological) in a thorough manner.

The assessment and plan section ties everything together. Diagnoses must be specific and supported by
documented evidence, such as test results or clinical findings. The plan should outline the next steps clearly,
including any diagnostic tests or labs needed to confirm the diagnosis. It should also include detailed
treatment instructions, specifying medication types, dosages, and frequency (if not included elsewhere in the
patient chart), along with clear follow-up instructions that indicate when and with whom the patient should
follow up.

Diagnoses and procedures must be coded with sufficient documentation to justify services. Incomplete or
conflicting information in the chart can lead to coding errors, which may result in claim denials. Proper
documentation ensures that the medical record supports accurate billing and reimbursement.

Compliance with documentation standards is key. Language should remain professional and follow etiquette
guidelines to ensure the record is clear and actionable. By focusing on these areas, we can ensure that
clinical documentation supports effective care, accurate billing, and regulatory compliance.

Conclusion

Our chapter readings for this unit cover important details related to the standard procedure code sets used for
coding services and procedures. CPT and HCPCS are valuable classification systems and all HIM
professionals should have a basic knowledge of their purpose and function. Medical coders and
reimbursement specialists should use updated coding data to avoid potential reimbursement issues such as
partial payments, denials, or rejections of insurance claims. This is why CDI plays such an instrumental role
as a bridge between coding and billing. If questions arise from clinical documentation, the proper course of
action is to seek clarification from a physician, lead coder, or the insurance company.

References

AAPC. (2024, January 29). What is clinical documentation. https://www.aapc.com/resources/what-is-clinical-

documentation?srsltid=AfmBOoqLEPFmfLe8GYvsCz5Iuksm7uXVXEcjlB7dHEfzupos0WaPcmww

French, L. L., & Turner, L. H. (2024). Administrative medical assisting (9th ed.). Cengage.

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