Question

1 Select two applications/system for clinical classification and coding encoder computer assisted coding (CAC) and appraise each vendor in terms of capacity to evaluate quality coding practice two possible implementation considerations/issues and three systems management challenges and training needs. Provide support for one system that you find as the best option with rationale.

2 Consider the principles and applications of classification systems, ICD-10-HCPCS) and medical record used within a clinical documentation improvement (CDI) program appraise. The value and challenges of a quality CDI program by defending the need for ongoing CDI program support and critique at least three challenges in the CDI process. make connection between auditing, accurate diagnostic and procedural coding with classification systems, and CDI reflect upon the need for CDI and best practices for ensuring compliance.

3 Critque one inter-operability issue that is possible within the health information exchange HIE, patient identity matching. appraise at least three best practices that address the issue.  

Answer 1

1. ANS: Microsoft encoder 4 pro: An encoder will not be in a situation to make a utilization of all the coding rules. For example, an encoder may not be great at executing the rules concerning an outpatient's sketchy conclusions. Despite the capacity of some encoders to aid in the sequencing of judgments, they here and there neglect to take after the primary of determination. For this situation, a grouper involves a product program which adjusts patients to comparative cases to a given gathering of installment. The frame gathering can be about methods, and judgments. Different angles to consider incorporate release demeanor, and additionally the framework's status pointer. Analysis related gatherings and wandering installment are the normal the groupers for both in-patients and out-patients, separately.

Computer assisted coding (CAC) system: It can perform an automatic assignment of any medical information which can get stored in electronic form. It is referred to as an automated system which requires no form of human assistance. The American Health Information Management Association (AHIMA) defines ACA as the use of the computer software which automatically produces a set of medical codes, both for review as well as validation. In this case, the systems require personal interventions at the stage of final code assignment. The ACA, together with the Automated Coding Systems are usually attached to the electronic health records.

2. ANS: ICD-10 (Worldwide grouping of ailments, tenth version) codes give more point by point data to estimating quality, security and viability of human services benefit. These codes notes maladies on wellbeing records, and tracks epidemiological patterns .They likewise aid therapeutic repayment choices. HCPCS (Social insurance Regular Strategy Coding Framework) is a coding framework used to recognize items, supplies and administrations that are excluded in the CPT codes. These codes speak to restorative methodology to Medicare, Medicaid and other outsider payers while coding bills.

CDI Process Challenges: Bridging the gap between clinical terminology used by health care providers and diagnostic coding terminology used for reimbursement. Hiring the right professionals in the CDI position, the one who has the basic knowledge of coding guidelines, one who understands the ethics and compliance issues surrounding the healthcare provider query process. To focus on maintaining correct and accurate documentation during care transitions and across all healthcare
settings.

Audit: Timely auditing, accurate diagnostic and procedural coding with classification systems helps to monitor the work of CDI professionals and ensures highest level of integrity of CDI programs. Clinical documentation is necessary for complying with quality measures. As it supports coding which is the basis of correct revenue and reimbursement, provides quality information which in turn supports care management in hospitals, there is a need for CDI. Proper examination of the documents for incomplete, ambiguous or conflicting information, physicians responding to CDI professionals queries timely and completely, active participation from treating physicians are some of the best practices to be followed to ensure compliance. These practices help hospitals to capture appropriate codes to adequately reimburse for the services they provide.

3. ANS: Advocate information operability and information exchange:

Critique one interoperability issue that is possible within the health information exchange (HIE) (e.g., patient identity matching). Appraise at least three (3) best practices that address the issue.

Patient Identity matching:

Patient identification matching is one of the major interoperability issues that is within electronic information exchange. These issues effects on healthcare quality and causes for medical errors.

Best Practices

Avoid duplicating patient records

At least three approved patient identifiers are used when providing care, therapy or services

Make a structured handover, transfer and discharge processes that include the use of three patient identifiers for each patient is used such as ISBAR (Identity, Situation, Background, and Recommendations)

Reference:

In Harman, L. B., & In Cornelius, F. H. (2017). Ethical health informatics: Challenges and opportunities.

LaRow, M. (2018). The patient-matching challenge: We can't keep doing what we are doing. Health Management Technology, 39(3), 12-13.

McComiskey, F. (2017). The fundamental managerial challenges in the role of a contemporary district nurse: A discussion. British Journal Of Community Nursing, 22(10), 489-494. doi:10.12968/bjcn.2017.22.10.489