2-2 Journal: Coding Errors and Compliance


In this journal assignment, you will identify coding errors or discrepancies in a mock patient record. You will then establish and write two policies to ensure that the errors will not occur in the organization in the future. Use the following resources to help you answer the critical element questions:

To complete this assignment, review the Module Two Journal Guidelines and Rubric document.

Overview: In this course, journals are used for reflection. Journal activities in this course are private between you and the instructor. For this journal task, you will identify coding errors. 

Prompt: First, read the AHIMA article “How Does Your Coding Measure Up? Analyzing Performance Data Gives HIM a Boost in Managing Revenue,” then review the Inpatient Face Sheet for coding inconsistencies and errors. Also review the index of current and accurate ICD-10-CM/PCS guidelines and codes in ICD-10-CM Coding Guidelines and ICD-10-PCS Coding Guidelines. The above resources are all linked in the 2-2 Journal assignment in the module.

Using the ICD-10-CM Coding Guidelines page, see if you can find additional discrepancies with this face sheet.

In a journal, address the following critical elements:

• What code errors or discrepancies are apparent in the patient record? Briefly describe the errors or discrepancies.

• Explain the importance of physician documentation in selecting a code.

• In what ways could a query to the physician be used to clarify any discrepancy or deficiency in the record?

• Draft two policy statements that would ensure compliance (i.e., that these errors will not happen in this organization in the future).

Defend your responses about compliance laws and issues using the resources presented in Module Two.


Guidelines for Submission: Submit the assignment as a Word document with double spacing, 12-point Times New Roman font, and one-inch margins. Your journal assignment should be 3 to 4 paragraphs in length.

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