ICD-10-CM Inpatient Diagnosis Coding: Source Documents

Outline:
Section 1: Introduction

About This Course

Learning Objectives

Section 2: Electronic Health Record

Overview: Inpatient Medical Record Source Documents

Electronic Health Record: Copying the Problem List

Documentation Used for Diagnosis Coding

Application of Basic Coding Guidelines

.Review

Summary

Section 3: Documents in the Inpatient Medical Record

Key Documents of the Inpatient Medical Record

Source Document: The History and Physical Report

Using the H&P for Coding

Progress Notes

Progress Notes Used for Procedure Coding

Consultant Reports

Operative Reports

Laboratory and Pathology Reports

Radiology Reports

Minor Procedure Reports

Physician Orders

The Discharge Summary

Review

Summary

Section 4 Reviewing the Medical Record

Reviewing Inpatient Medical Records for Coding

Concurrent Coding

Post-Discharge Coding

Using Encoders in the Post-Discharge Coding Process

Gaining Experience

Review

Summary

Section 5: Conclusion

Course Summary

Course Contributor

References

Jane Conway is a Revenue Cycle, Coding, and CDI subject matter expert, content writer for Relias. She has ten years of experience in writing and maintaining ICD-10-CM/PCS eLearning curricula for inpatient and outpatient hospital settings. She is also an author and peer reviewer for other revenue cycle eLearning products. She has extensive knowledge in risk adjustment for CMS, HHS, and commercial payers. Jane has worked in healthcare for almost 30 years both in Health Information Management and pharmacy. Her pharmacy background adds a depth of knowledge to her courses. Jane is a Registered Health Information Administrator (RHIA), Certified Documentation Improvement Practitioner (CDIP), a Certified Risk Adjustment Coder (CRC), Certified Coding Specialist (CCS), and an AHIMA approved ICD-10-CM and ICD-10-PCS trainer. She is also a Certified Pharmacy Technician (CPhT).  Jane earned a Bachelor's degree in Health Information Management from the State University of New York Polytechnic Institute where she was the recipient of the New York Health Information Management Association (NYHIMA) Academic Achievement Award. 

Jane is active in NYHIMA, where she has served on the program planning committee and the education committee. Jane has also served as a credentials officer for NYHIMA. She recently was a keynote speaker at the NYHIMA annual conference and presented to both AAPC and CNYHIMA local meetings on several pertinent topics. She has also written several articles about new medical treatments for the NYHIMA newsletter. 

Disclosure: Jane Conway, RHIA, CCS, CRC, CDIP, CPhT, ICD-10-CM/PCS Trainer has no Relevant Financial or Non-Financial Relationship with ineligible companies to disclose.