TCO
3
Given a health record, accurately apply coding skills to support the reimbursement process.
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Unfortunately, I was unable to have much exposure to the coding part of the medical records at Orchard Park. They only have one coder and her main coding occurs when a patient is first admitted. She fills out a form such as the one I have pictured on the left, listing all of the diagnoses of the patient. She then gives it to the MDS coordinator who reviews the codes for accuracy and ranks them according to relevancy and importance. Then the list is given to medical records to enter into the NetSolution database in the patient file. I had the opportunity to enter in the codes several times. I learned:
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Ranks 3, 4, and 5 are reserved for therapy diagnoses, if applicable.
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The first 10 are considered the most vital diagnosis codes.
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ICD-10-CM is the coding system used at the facility.
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The coder uses the ICD-10 coding book, not an encoder or grouper. They were not familiar with the 3M software.
I did have an opportunity to practice coding, however. I think that Dianne took pity on me because I wanted to code so badly. So, we sat down with the ICD-10-CM codebook and practiced coding a patient's diagnoses. I was surprised at how well I was able to abstract the information from the record and come to conclusions about some of the diagnoses. At that time I was also able to use my 3M software provided by DeVry to demonstrate how 3M worked and how to look up codes. I explained about MS-DRGs since they do not use them there and Dianne was not familiar with them.
