Help with advance medical coding final

HIM285 – Advanced Medical Coding

Final Project

Directions: After updating the auditing form from your midterm submission (use the comments provided to you in the grading feedback to update), use your auditing tool (this is uploaded below)to complete an internal audit for the HIM department (

Case Study 1

and 2). After you complete the audit, provide a 5 slide PPT to present to the HIM director that explains items that may need to be updated in the current coding policies and procedures. Title slide, transition slides and reference slides (if applicable) do not count towards the 5 slides. Submit your completed audit tool for Case Study 1,

Case Study 2

, and the PPT to the drop box by the due date.

Case Study 1

Name: Willow, McIntyre

DATE OF OPERATION: 07/15/2021

PREOPERATIVE DIAGNOSIS: Multiparity, seeking permanent family planning.

POSTOPERATIVE DIAGNOSIS: Multiparity, seeking permanent family planning.

PROCEDURE PERFORMED: Bilateral partial salpingectomy.

SURGEON: Gina LeShay, MD

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating suite and placed in the supine position. She had her abdomen appropriately prepped and draped and her bladder emptied. The skin in and about the umbilicus was injected with a mixture of Marcaine and Xylocaine with epinephrine and then a vertical incision was made through the umbilicus and then carried through the natural defect into the abdominal cavity. The fascia was then incised. The patient was placed in slight Trendelenburg. The right fallopian tube was visualized and grasped with a ring clamp and then Babcock clamps and followed to its fimbriated end. The midportion was then elevated and a window was made in the mesosalpinx. Two Kelly clamps were placed proximally and distally, and the midsection removed. The tube was then tied proximally and distally using 2-0 plain gut. The tubal segments were then injected with the same local anesthetic. A similar procedure was done on the left. The peritoneum and fascia were closed in one layer using 0 Vicryl in a running nonlocked fashion. The skin edges were reapproximated using a subcuticular stitch of 4-0 undyed Vicryl. A sterile dressing was applied. The patient was taken to the recovery room in stable condition. The patient will be discharged later today.

The ICD-10-PCS code that was submitted was 0UT7FZZ

The ICD-10-CM code that was submitted was Z30.2

Answer the following questions:

Do you agree with the codes that were found?

oIf so, provide the exact steps (Index term, numbers found, tabular located etc.) that you took to verify that the code was correct.

oIf you believe the codes are not correct, provide the steps you took to find the correct codes.

oWhat did you look under in the Index of the manuals?

§PCS

RO

§ICD-10-CM

oWhat code did you find?

§PCS§ICD-10-CM

oWhere did you look in the tabular?

§PCS chart

§ICD-10-CM

o

How did you find the code?

Case Study 2

Outpatient—Physician’s Office

Patient Name: Mary Ballard

Diagnosis: Cholinergic toxic syndrome

A 40-year-old established patient visited the physician’s office after experiencing symptoms of dizziness, headaches, excessive salivation, and lacrimation. Five days ago, the patient was started on treatment of 5 mg pilocarpine hydrochlorothiazide (HCTZ) tablets, 3 times each day for dry mouth. That treatment was prescribed for the side effect of dry mouth, which resulted from radiation therapy for cancer of the larynx. The patient stated she took more of the pilocarpine HCTZ medication than prescribed because she was hoping for faster results. A detailed history and physical were performed along with a drug assay, which revealed that the patient was experiencing cholinergic toxic syndrome as a reaction to the overdose of pilocarpine HCTZ. The physician ordered 0.02 mg atropine sulfate to be injected intramuscularly to counteract the cholinergic toxic syndrome reaction. The physician spent 30 minutes discussing with the patient the importance of taking the pilocarpine HCTZ medication as prescribed.

99213, 80299, 96372, J0461, J0461

T44.1X1A

Answer the following questions:Do you agree with the codes that were found?oIf so, provide the exact steps (Index term, numbers found, tabular located etc.) that you took to verify that the code was correct.oIf you believe the codes are not correct, provide the steps you took to find the correct codes.oWhat did you look under in the Index of the manuals?

§CPT/HCPCS

§ICD-10-CMoWhat code did you find?§CPT/HCPCS§ICD-10-CMoWhere did you look in the tabular?§CPT/HCPCS§ICD-10-CM How did you find the code? HAPPY HOSPITAL
* AUDIT FORM
*
AUDIT FORM *
AUDIT FORM
Coder Name:
Admission Date:
Discharge Date:
AUDIT DATE:
AUDITIERS NAME
AUDITORS SIGNATURE
TIME START AUDIT
TIME ENDED AUDIT
Diagnosis:
CODE(S) SELECTED
CODE(S) AUDITED
OVER CODED
UNDER CODED
PROVIDERS NAME
PLACE OF SERVICE
SERVICE TYPE
DATE OF SERVICE:
PATIENTS NAME:
INSURANCE PROVIDER:
PATIENT ID #
PATIENTS DATE OF BIRTH:
INSURANCE ID:
PATIENT GENDER:
CORRECTED
OTHER:
MISCODED
*
CHIEF COMPLAINT
MEDICALLY APPROPRATE HISTORY AND EXAM DOCUMENTED?
YES.
RANK
TIME
OFFICE VISIT
MINIMAL
PROBLEM FOCUSED
NEW
CPT
CODES
TIME
99201
EXPANDED PROBLEM
FOCUCED
DETAILD
99202
99203
COMPREHENSIVE
99204
1529min
3044min
4559min
6074min
EST
CPT
CODES
99211
99212
99213
99214
99215
1019min
2029min
3039min
4554min
COMPREHENSIVE
99205
(NEW PATIENT)
SIGNIFICANT, SEPARATE
-25
-25
SERVICE
TOTAL DURATION OF NEW PATIENT
USE WITH 99205
OFFICE OR SERVICES
NEW PATIENT 75 MIN OR LONGER
99417 (DO NOT CODE
ALONE)
75-89 MIN
99205 X 1& 99417 X 1
90-104 MIN
99205 X 1 & 99417 X 2
105 MIN OR MORE
99205 X 1 & 99417 X 3
OR MORE FOR EACH
ADDITIONAL 15 MIN
USE WITH 99215
TOTAL DURATION OF ESTABLISHED
PATIENT OFFICE OR OTHER
OUTPATIENT SERVICES
ESTABLISHED PATIENT 55 OR LONGER
55-69 MIN
99417 (DO NOT CODE
ALONE)
99215 X & 99417 X 1
70-84 MIN
99215 X 1 & 99417 X 2
NO
CODED
MOD
85 MIN OR MORE
99215 X 1 & 99417 X 3
OR MORE FOR EACH
ADDITIOONAL 15 MIN
USE WITH 99245
TOTAL OF OFFICE OR OTHER
OUTPATIENT CONSULTATION
SERVCES
LESS THAN 70 MIN
99417(DO NOT CODE
ALONE)
70-84 MIN
99245 X 1 & 99417 X 1
80-99
99245 X 1 & 99417 X 2
100 MIN OR MORE
99245 X 1 & 99417 X 3
OR MORE FOR EACH
ADDITIONAL 15 MIN
WELL VISIT
< 1YEAR 1-4 YEARS 5-11 YEARS 12-17 YEARS 18-39 YEARS 40-64 YEARS 65 YEARS + NEW CPT CODES 99381 99382 99383 99384 99385 99386 99387 EST CPT CODES 99391 99392 99393 99394 99395 99396 99396 CODED MOD Time (Time may include any of the following (when not reported separately)): • Preparing to see the patient such as reviewing the pt.’s record, review of tests, etc. • Obtaining and/or reviewing separately obtained history • Performing a medically appropriate history and examination • Counseling and educating the patient, family, and/or caregiver • Ordering prescription medications, tests, or procedures • Referring and communicating with other health care providers when not separately reported during the visit • Documenting clinical information in the electronic or other health record • Communicating results to the patient/family/caregiver Yes YES • Independently interpreting results when not separately reported • Coordinating the care of the patient when not separately reported No NO FACE-TO-FACE VISIT TIME WAS DOCUMENTED FOR THIS ENCOUNTER -------------------- MINUTES TOTAL AMOUNT OF TIME DOCUMENTED HAPPY HOSPITAL – AUDIT FORM WAS THE CORECT LEVEL OF MDM CODED YES NO ONLY 2 OF THE 3 SECTIONS NEED TO BE COMPLETED TO DETERMINE THE MDM, WHICH CORRELATES WITH LEVEL OF SERVICE NUMBER & COMPLEXITY OF PROBLEM(S) Number and Complexity 5: chronic illness w/severe exacerbation (a) a. May require admission/aggressive treatment & care escalation. 5: illness/injury w/life or body threat (b) b. Threat to life/body function w/out treatment. 4: chronic illness with exacerbation (c) c. Chronic problem worse from baseline. 4: ≥2 stable, chronic illnesses (d) d. Problem is at its baseline. 4: undiagnosed new problem, uncertain outcome (e) e. New, serious (not minor) undiagnosed problem. 4: acute illness w/systemic sx (f) f. Serious systemic symptoms in associated illness. 4: acute, complicated injury (g) g. Extensive injury or impacting multiple body systems, has multiple treatment options, or morbidity. 3: 2 minor problems (h) h. ≥2 problems that are self-limited. 3: 1 stable, chronic illness (i) I. Problem is at its baseline. 3: acute uncomplicated illness/injury (j) j. Low risk of morbidity, little-to-no mortality risk. 3: stable, acute illness (k) k. New/recent problem, but stable. 3: uncomplicated illness/injury requiring hospitalization (l) l. Relatively minor problem, but still needing hospital care. 2: 1 minor problem (m) m. Problem that is self-limited. RISK OF MORBIDITY, MORALITY, OR COMPLICATIONS Risk level High: parenteral controlled substances, elective/emergency major surgery decision, hospitalized considered, or DNR/de-esc considered Moderate: prescription drug management, minor/major surgery decision, or limited by social DOH See Evidence for details. RISK LEVEL HIGH HIGH MODERATE LOW MINIMAL PRESENTING PROBLEM(S) DIAGNOSTIC PROCEDURE ORDERED -One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment -cardiovascular imaging studies with contrast, with identified risk factors -acute or chronic illness or injures that pose a threat to life or body functions, e.g., multiple trauma, acute MI pulmonary -cardiac electrophysiological tests -diagnostic endoscopies with identified risk factors MANAGEMENT OPTIONS -elective major surgery (open, percutaneous, or endoscopic) with identified risk factors -emergency major surgery (open, percutaneous, or endoscopic) embolus, severe raspatory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute failure -discography -drug therapy requiring intensive monitoring for toxicity -an abrupt change in neurologic status, e.g., seizure, TIA, weakness, or sensory loss MODERAT E -One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment -Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test -two or more stable chronic illnesses -Diagnostic endoscopies with no identified risk factors -undiagnosed new problem with uncertain prognosis, e.g., lump in breast, rectal bleeding -acute illness with systematic symptoms, e.g., pyelonephritis, pneumonitis, colitis -acute complicated injury, eg head injury with brief loss of consciousness -parenteral controlled substances -Deep needle or incisional biopsy -Cardiovascular imaging studies with contrast and no identified risk factors, e.g., arteriogram, cardiac catheterization -decision not to resuscitate or to deescalate care because of poor prognosis -Elective major surgery (open, percutaneous or endoscopic) with no identified rick factors -Prescription drug management or prescribing new drug (add/change/delete meds) -Therapeutic nuclear medicine -IV fluids with additives -Closed treatment of fracture or dislocation without manipulation -Obtain fluid from body cavity, e.g., lumbar puncture, thoracentesis, culdocentesis LOW -Two or more self-limited or minor problems -One stable chronic illness, e.g. well controlled hypertension or non-insulin dependent diabetes, cataract, BPH -Acute uncomplicated illness or injury, e.g. -Physiologic tests not under stress, e.g., pulmonary function tests -Non-cardiovascular imaging studies with contrast, e.g. barium enema -Over the counter drugs -Minor surgery with no identified risk factors -Physical therapy -Superficial needle biopsies cystitis, allergic rhinitis, simple sprain MINI MAL -one self -limited or minor problem, e.g., cold, insect bite, tinea corpora -Clinical laboratory tests requiring arterial puncture -Occupational therapy -Skin biopsies -IV fluids without additives -laboratory tests requiring venipuncture -Rest -Gargles -Chest x-rays -Elastic bandages -EKG/EEG -Urinalysis -Superficial dressings -Ultrasound, e.g. echocardiography -Drug maintenance (refill meds) -KOH prep AMOUNT AND OR COMPLEXITY OF DATA Tests ordered. Unique item like a CBC, troponin, CT scan, EKG, etc. >3
2
1
0
Tests results reviewed (excluding labs)
Review of imaging, EKGs, etc.
>3
2
1
0
Prior external notes reviewed.
Outside ED/hospital setting or specialty
>3
2
1
0
Assessment requiring and independent historian.
Independent historian: anyone who provides additional
information patient can’t provide, does not include
interpreters.
YES
NO
Independent interpretation of tests
Test interpreted by ER doctor, but formal read will be
done (and billed for) by another HCP.
YES
Discussed management/test interpretation
w/external professional.
With external physician/other qualified health care
professional/appropriate source, not separately
reported.
YES
NO
NO
HAPPY HOSPITAL – AUDIT FORM
PATIENT HISTORY
WAS HISTORY
CODED
HISTORY OF PRESENT ILLNESS
STATUS OF 3 CHRONIC PROBLEMS. 1. ____
2 ______
yes
no
3_____
OR
CHOOSE ELEMENTS
_____ QUALITY ______LOCATION. _______DURATION _______SEVERITY
_______TIMNIG ________CONTEXT _________MODIFYING FACTORS _______ASSOCIATED SIGNS/SYMPTOMS
STATUS OF 1-2
CHRONIC CONDITIONS
OR
STATUS OF 1-2
CHRONIC CONDITIONS
OR
STATUS OF 3
CHRONIC CONDITIONS
OR
STATUS OF 3
CHRONIC CONDITIONS
OR
BRIEF
1-3
ELEMENTS
BRIEF
1-3
ELEMENTS
EXTENDED
>4
ELEMENTS
EXTENDED
>4
ELEMENTS
REVIEW OF SYSTEMS
____CONSTITUTION SYMTOMS
____EYES.
____EARS, NOSE, MOUTH, THROAT
____CARDIOVASCULAR
____RESPIRATORY
____GASTROINTESTINAL
____GENITOURINARY.
____INTEGUMENTARY.
____MUSCULOSKELETAL
____NEUROLOGICAL.
____PSYCHIATRIC.
____ENDOCRINE
____HEMATOLOGIC/LYMPHATIC.
____ALLERGIC/IMMUNOLOGIC
NA
PERTINENT TO PROBLEM
EXTENDED
COMPLETE
1
(PERTINENT TO PROBLEM
AND OTHER RELATED
SYSTEMS)
(PERTINENT AND ALL
RELATED SYSTEMS)
10 TOTAL
2-9 TOTAL
PAST MEDICAL, FAMILY & SOCIAL HISTORY
PAST MEDICAL
FAMILY
SOCIAL
___CURRENT MEDICATION
___HEALTH STATUS OR CAUSE OF
DEATH OF PARENTS, SIBLINGS, AND
CHILDREN
___LIVING ARRANGEMENTS
___PRIOR ILLNESS AND INJURY
___OPERATIONS AND
HOSPITALIZATIONS
___HEREDITARY OR HIGH-RISK
DISEASES
___AGE-APPROPRIATE
IMMUNIZATIONS
___DESEASES RELATED TO CC, HPI,
ROS
___ALLERGIES
___MARITAL STATUS
___SEXUAL HISTORY
___OCCUPATIONAL HISTORY
___USE OF DRUGS, ALCOHOL, OR
TABACCO
___EXTENT OF EDUCATION
___DIETARY STATUS
___CURRENT EMPLYMENT
___OTHER
NA
NA
PERTINENT
COMPLETE
1 AREA
2-3 AREAS
******COMPLETE PAST MEDICAL, FAMILY SOCIAL HISTORY
3 HISTORY AREAS FOR ALL NEW PATIENTS
2 HISTORY AREAS FOR ALL FOLLOW UP/ESTABLISHED VISITS OR PATIENTS SEEN IN EMERGENCY DEPARTMENT
PROBLEM FOCUSED
EXPANDED PROBLEM
FOCUSED
DETAILED
COMPREHENSIVE
EXAMINATION
LIMITED TO AFFECTED
BODY AREA OR ORGAN
SYSTEM
AFFECTED BODY
AREA/ORGAN SYSTEM
AND OTHER
SYMPTOMATIC OR
RELATED ORGAN SYSTEMS
EXTENDED EXAM OF
AFFECTED BODY
AREAS/ORGAN SYSTEMS
AND OTHER SYPTOMATIC
OR RELATED ORGAN
SYSTEMS
BODY AREA OR ORGAN
SYSTEM
BULLETED ITEMS
1
1-5
PROBLEM-FOCUSED
2-7
6-11 OR MORE
EXPANDED
PROBLEM-FOCUSED
2-7
12-17 OR MORE FOR 2 OR
MORE SYSTEMS
GENERAL MULTI-SYSTEM
COMPLETE SINGLE ORGAN
SYSTEM
>8
18 OR MORE FOR 9 OR MORE
SYTEMS
NOT DEFINED
REFER TO GUIDELINE
DETAILED
COMPREHENSIVE
GENERAL MULTI-SYSTEM EXAMINATION
CONSTITUTIONAL
PROCEDURES WITH NO ADEQUATE CODES
__3 OF 7 BP. PULSE, RESPIR,TMP,WGT
_____________________________________
__GENERAL APPEARANCE
_____________________________________
_____________________________________
EYE
(CODES START AT H00-H59)
WAS THERE SURGRY ON EYE?
__CONJUNCTIVAE, LIDS
__OD
__OS
__BILATERAL
__EYE:PUPPILS,IRISES
Z98.41-SURGREY
Z98.42SURGERY
Z98.49-SURGRY
__OPHTHAL EXAM-OPTIC DISC, POSSEG
__CONJUNCTIVA H10*
__CORNEA H18*
__SCLERA H15*
__IRIS H21*
__LENS H27*
__VITREOUS H43*
__RETINA H35*
__CHOROID H31*
ENT
WAS THERE SURGRY?
__EARS, NOSE
__OTO EXAM-AUD CANALS, TYMP MEMBER
NECK
NOTES
__NECK
__THYROID
RESPITORY
CARDIOVASCULAR
__RESPITORY EFFORT
__PALPATION OF HEART
__PERCUSSION OF CHEST
__AUSCULTATION OF HEART
__PALPATION OF CHEST
__CAROTID ARTERIES
__AUSCULTATION OF LUNGS
__ABDOMINAL AORTA
__FEMORAL ARTERIES
__PEDAL PULSE
__EXTREM FOR PERIPH EDEMA/ VARICOSCITIES
CHEST
GASTROINTESTINAL
__INSPECT BRESTS
__ABD
__PALPATATIONS OF BREAST& AXIIAE
__LIVER, SPLEEN
__HERNIA
__ANUS, PERINEUM, RECTUM
__STOOL FOR OCCULT BLOOD
GU/FEMAIL
GU/MALE
__FEMALE: GENITALIA, VAGINA
__SCROTOL AREAS
__FEMALE URETHRA
__PENIS
__BLADDER
__DIGITAL RECTAL OF PROSTATE
__CERVIX
__UTERUS
__ ADNEXA/PARAMETRIA
LYMPHATIC
__LYMPH: NECK
__LYMPH: AXILLAE.
__LYMPH: GROIN
MUSCULOSKELETAL
__LYPH: OTHER
NOTES
__GAIT
__PALPATION DIGITS, NAILS
__HEAD/NECK: INSPECTION, PALP
__HEAD/NECK: MOTION +/-PAIN, CREPIT
__HEAD/NECK: STABILITY +/- LUX, SUBLUX
__HEAD/NECK: MUSCLE STRENGTH & TONE
SKIN
__SPINE/RIB/PELV: INSPECT, PALP
__SKIN: INSPECT SKIN & SUBCUT TISSUES
__SPINE/RIB/PELV: MOTION
__SKIN: PALPATION SKIN & SUBCUT TISSUES
__SPINE/RIB/PELV: STABILITY
__SPINE/RIB/PELV: STRENGTH AND TONE
NEURO
__R. UP EXTREM: INSPECT, PALP
__NEURO: CRANIAL NERVES +/- DEFECTS
__R. UP EXTREM: MOTION +/-PAIN, CREPIT
__NEURO: DTRs +/- PATHOLOGICAL REFLEXES
__R. UP EXTREM: STABILITY +/- LUX, SUBLUX
__NEURO: SENSATIONS
__R. UP EXTREM: MUSCLE STREGTH & TONE
__L. UP EXTREM: INSPECT, PALP
PSYCHIARY
__L. UP EXTREM: MOTION +/-PAIN, CREPIT
__PSYCH: JUDGEMENT, INSIGHT
__L. UP EXTREM: MUSCLE STRENGTH & MORE
__PSYCH: ORIENTATION TIME, PLACE, PERSON
__R. LOW EXTREM: INSPECT, PALP
__PSYCH: RECENT, REMOTE MEMORY
__R. LOW EXTREM: MOTION +/-PAIN, CREPIT
__PSYCH: MOOD, AFFECT (DEPRESSION, ANXIETY)
__R. LOW EXTREM: STABILITY +/- LUX, SUBLUX
__R. LOW EXTREM: MUSCLE STRENGTH & MORE
__L. LOW EXTREM: INSPECT, PALP
__L. LOW EXTREM: MOTION +/-PAIN, CREPIT
__L. LOW EXTREM: STABILITY +/- LUX, SUBLUX
__L. LOW EXTREM: MUSCLE STRENGTH & MORE
WHERE APPROPRAITE CODES USED?
YES
NO
HAPPY HOSPITAL – AUDIT FORM
WHERE MEDICATIONS ORDERS WRITEN?
YES
NO
IS FOLLOW UP CARE NEEDED?
YES
NO
WAS PATIENT IN HOSPITAL?
IF PATIENT WAS IN HOSPITAL?
RELEASED-__________
DAYS IN HOSPITAL-__________
PRE-AUDIT
POST AUDIT
VARIANCE
# OF CODES______
IS PHYSISIAN QURY NEEDED:
HAPPY HOSPITAL – AUDIT FORM
CHECKLIST- BEFORE TURNING IN-
ARE CLAIMS ACCURATELY CODED AND DOCUMENTED?
ARE CLAIMS SUBMITTED WITHIN THE TIME FRAME?
IS COMPLIANCE WITH HIPAA AND ACA ENSURED?
ARE MEDICAL CODES ACCURATE AND APPROPRIATE?
IS DOCUMENT COMPLETE AND CLEAR?
DO BILLED CHARGES ALIGN WITH CONTRACTED RATES?
ARE DENIAL MANAGEMENT PROCESSES EFFECTIVE?
IS BILLING PROCESS EFFICIENT AND TIMELY?
HAPPY HOSPITAL – AUDIT FORM
INITALS
HAPPY HOSPITAL – AUDIT FORM
HAPPY HOSPITAL – AUDIT FORM
Outpatient Coding Audit Tool
Coder Name:
Auditor Name:
Date of Audit:
Admission Date:
Discharge Date:
Diagnoses
Coder ICD-10-CM
Diagnoses Codes
Auditor ICD-10-CM
Diagnoses Codes
Coding Guideline
Referenced for
Change
Comments/Rationale
PDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
Procedures
Coder
HCPCS/CPT
Code
PPx
SPx
SPx
SPx
SPx
Coder
Modifier
Auditor
HCPCS/
Auditor
Modifier
Coding Guideline
Referenced for
Change
Comments/Rationale
Outpatient Coding Audit Tool
Coder Name:
Auditor Name:
Date of Audit:
Admission Date:
Discharge Date:
Diagnoses
Coder ICD-10-CM
Diagnoses Codes
Auditor ICD-10-CM
Diagnoses Codes
Coding Guideline
Referenced for
Change
Comments/Rationale
PDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
Procedures
Coder
HCPCS/CPT
Code
PPx
SPx
SPx
SPx
SPx
Coder
Modifier
Auditor
HCPCS/
Auditor
Modifier
Coding Guideline
Referenced for
Change
Comments/Rationale
Inpatient Coding Audit Tool
Coder Name:
Auditor Name:
Date of Audit:
Admission Date:
Discharge Date:
Diagnoses
Coder ICD-10-CM
Diagnoses Codes
Auditor ICD-10-CM
Diagnoses Codes
Coding Guideline
Referenced for Change
Comments/Rationale
Coding Guideline
Referenced for Change
Comments/Rationale
PDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
SDx
Procedures
Coder ICD-10-PCS
Procedure Codes
Auditor ICD-10-PCS
Procedure Codes
PPx
SPx
SPx
SPx
SPx
DRG
Original Coder DRG
DRG
Auditor DRG
Coding Guideline
Referenced for Change
Comments/Rationale