Health Information Manager Research Paper

Health Information Manager (HIM) plays a crucial role coding health record or clinic record. (Sayles 114). The reason because, HIM keep accurate records of the patient symptoms which include medical histories, medical procedures, treatments, and diagnostic testings such as labs, radiology reports, and X-Rays. If the records are not coded correctly on the assignment, it can cause the facility to lose money or fraud. They are thousand different diagnoses we cannot make any assumption we have to appropriately code the information precise. ( Person) I research a scenario from the internet from Medical and Billing.org. I will write about how each section or information assist the coding process.
This scenario has taken place in a doctor’s office.

The patient is a 27-year-old white male. This was his first visit to the office. His is allergic to penicillin but has no other outstanding medical history. The patient presented with chills, headache, cough, fever 101 degrees, and difficulty breathing. The doctor examines the patient with stethoscope yield heavy rales. Percussion test on thorax suggests buildup the lungs. Stethoscope pneumonia suspected. The doctor obtained his blood sample for Antistreptolysin Otitler. The results yield level of ASO above 200. He diagnosis of Streptococcal pneumonia. The doctor prescribed the patient two of 500 mg Zithromax and scheduled the patient for next week follow-up.
Using information the from the above scenario will help us to code the diagnosis. There are five processes of analysis the health record for coding. First, I will analyze the case. Second review the key report to identify which procedure matches the coding assignment for the records. Third, examined the data from the medical or clinical report. Fourth, evaluate and exclude what information should not be coded or which procedure needs to be bunded. The final step is to review the medical report and consider the reimbursement or make an adjustment and refinement of the selected code. (Person)
Since the scenario is a clinical record, I would use ICD-10 (International Classification Diseases) for stethoscope pneumonia and use CPT code for the following procedures. The first procedure I will code is the evaluation and management (E/M) which includes medical history, doctor decision making, and detailed examination which included medication because is part of the decision making. The second procedure would be the doctor performed the blood test on the patient. To summarize, I will enter in the Superbill are patient Information, provider Information or facility information, procedure Information, and diagnostic Information which might include lab, radiology, or X-ray.
What I find out doing my research and reading the textbook coding can be very complex and have to be error free. For coder to be successful, we must follow the step by step process doing this step the coding will be accurate and precise.