Nt1330 Unit 6 Assignment

1) As a certified medical coder (CCA 11/2012), I have contributed to the HIMS department by helping code inpatient encounters from patients in the Residential Rehab Unit as well as outpatient encounters from the other clinics at this VA applying the official coding conventions outlined in the International Classification of Diseases 9th revision handbook as well as in the VHA’s Official Coding Guidelines, V11.0 dated August 10, 2011. Having coded many encounters over the past 3 years, I can easily determine the main condition after study that is chiefly responsible for a patient’s admission to the hospital. ICD-9-CM defines this as the primary diagnosis code and I find that it is most important to list this code first in your documentation

When the committee was deciding whether or not to control the station’s fax cover sheets, I immediately gave guidance to the committee by sharing my experiences from the PCA inspection last year and provided insight into forms control by explaining what it is supposed to accomplish. Furthermore, I pointed out that all of our cover sheets need to have a specific regulatory language on them and that this regulatory language must be on all outgoing cover sheets from any VA facility. I have also shared my expertise on EOC/Privacy rounds noting that there were several different fax cover sheets found throughout the facility in violation of current privacy guidelines. At the next meeting, I am getting ready to share my research on a formal forms approval process for every form at this facility. Research I conducted over the phone and online with other VA facilities in the VISN, shows that the regulations for forms and templates only extend to medical forms and I believe this will allow us enough room to have a locally governed forms control process here that formally approves and numbers any non-medical forms, posters, or flyers posted at this facility. This will keep unauthorized information from getting posted anywhere in the facility because we will have a formal form number on all approved

I then logged the data into spreadsheet formats so that our team could work with a set number of secure messages auditing them on a pass/fail basis. Looking for quality messages that talked about a patient’s symptoms or asked for dosage clarification, for example, would earn a pass rating. This report also allowed us to look for inappropriate and non-productive chat messages with no medical purpose whatsoever. Such messages would fail the