Course Code: REL-RCC-ICD10-IDCSD
Hours: 1
Type: Online Course
Content Expiration Date: 12/31/2027
Learning Objectives:
Recognize the inpatient medical record source documents used for coding.
Categorize valid documentation contained in each source document that can be used appropriately for coding.
Describe the process when there is a conflict in patient documentation.
Identify procedures taken when source documents are missing.
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
Instructor: Jane Conway, RHIA, CCS, CRC, CDIP, CPhT, ICD-10-CM/PCS Trainer
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.
Target Audience:
The target audience for this course is: Coding Specialists; in the following settings: Acute Care Facility.
Relias Learning will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Relias Learning has a grievance policy in place to facilitate reports of dissatisfaction. Relias Learning will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias Learning at support@reliaslearning.com.
All courses offered by Relias Learning, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.