I learned the set of key data elements from the patient's health record which are important for the accurate and quality coding process. I successfully abstracted all pertinent information in the different case studies.
I was able to determine primary & secondary diagnosis. I learnt that in outpatient setting the first listed diagnosis is used while in inpatient settings condition established after study to be mainly responsible and which is considered as 'Principle Diagnosis'. In Outpatient settings determining APC and status indicator is key for payment reimbursement process.
In inpatient settings, determining DRG is key for proper reimbursement. Assignment of accurate POA is very important which helped to differentiate between diagnosis that were present on admission and diagnosis that were determined after the admission. I also learned that the assigment of correct patient discharge status code (such as discharge to be home or another facility) is just as important as any other codes.
I was able to put all primary and secondary diagnosis with CC/MCC in inpatient case studies to determine accurate DRG which affects reimbursement and relative weight.
In physician cases, I learned to put accurate E/M codes, place of services and diagnosis codes for medical necessities.
I successfully worked on hundreds of coding scenarios using the Clintegrity and learned how to use 'References' such as CPT coding clinic, ICD-10 coding clinic etc. The important take aways for me was - understanding the differences between inpatient and outpatient physician cases and importance of following the coding guidelines to report the accurate codes.
Artifacts
Coding abstract - In-patient, Out-patient and physician case studies.