Discuss the role of coding with the key features of an electronic health record (EHR) system and clinical document standards.

Apply diagnostic and procedure codes according to current guidelines using common classification systems, taxonomies, nomenclatures and terminologies
Identify the documentation needs that relate to quality coding practices
Discuss the role of coding with the key features of an electronic health record (EHR) system and clinical document standards.
Discuss the importance and relevance of Computer-Assisted Coding along with coding problems that may arise.

Course outcome(s) practiced in this unit:
HI253-5: Appraise a health record for deficiencies needed for quality coding (Bloom’s Level 4)

AHIMA’s Professional Coding Approved Program (PCAP) Mapping:
Domain I. Data Content, Structure & Standards (Information Governance)
Subdomain I.A Classification Systems
1. Apply diagnosis/procedure codes according to current guidelines (Bloom’s Level 3)
Classification Systems
ICD (ICD-9-CM, ICD-10, ICD-10-CM/PCS)
Taxonomies
Clinical Care Classification (CCC)
Nomenclatures
CPT, DSM, RxNorm
Terminologies
LOINC, SNOMED CT
Instructions:

Part 1: Coding Scenario Worksheet (coding practice): Complete the coding scenarios worksheet indicated in Part 1 below by indicating the appropriate codes.

Part 2: Nuance Quantim Physician Query Activity: Please access the AHIMA’s Virtual Laboratories (VLabs) at http://academy.ahima.org/ website. Within the Virtual Lab (My Learning), go to the Virtual Lab applications and open the Nuance Quantim Encoder application and complete the Nuance Quantim #6 Activity on Physician Query activity with a passing score of 100% and appropriately identify the documentation needs that relate to quality coding practices. Answer the provided questions and submit a screen shot of your completed Physician Query activity in the Part 2 section of the Assignment Worksheet.
Part 3: Electronic Health Record and Coding Systems:

A. VistA Simulation: Please access the AHIMA’s Virtual Laboratories (VLabs) at http://academy.ahima.org/ and follow the instructions under Part 3. Once completed, take a screen shot of the completion page and attach to the appropriate Part 3 section of the Assignment Worksheet. Remember to review the VLab instructional sheet in Doc Sharing if you trouble navigating.
B. EHR and Coding Resources Comparison Table: Answer the question indicated and support your answer by providing a table to include where the resource would be located and how best to access.
Part 4: Computer-Assisted Coding: Refer to the information from your Unit 10 Discussion Board and provide your answers/discussion in the Part 4 section of the Assignment Worksheet.

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