HI253: Medical Coding I

INSTRUCTIONS: Part 2: Auditing and Feedback

• After you code the chart, choose another teammate’s chart to audit using Template 2.
• Review the case from a new perspective comparing your previous codes to their codes.
• Enter their codes and your final set of codes into the auditing form and discuss any differences between the codes reported.
• Attach your audit to your classmate’s post by pasting your audit findings into a reply to their post by Tuesday night.

Template 2: Chart Review Audit

I audited _________ review of chart #_______.

The reported principal diagnosis was _________. My audit confirms / disagrees with this ________________________.

Additional reported diagnoses were ____________. My audit confirms / disagrees with this diagnosis.

Services reported were a _____________. My audit confirms / disagrees with this procedure.

Example Audit Post:

I audited Sally’s review of chart #35587.

The reported principal diagnosis was acute appendicitis, unspecified (K35.80). My audit disagrees with this and found the diagnosis to be other appendicitis (recurrent) (K36).

Additional reported diagnoses were type 2 diabetes mellitus without complications (E11.9). My audit confirms this diagnosis.

Services reported were a laparoscopic appendectomy (44970). My audit confirms this procedure.

Participation Expectations: Please engage on this topic throughout the unit by posting one reply post by the end of the unit. Please utilize the provided templates when making your posts. There are no specific word counts for this discussion board assignment.

CLASSMATE POST #1

I reviewed chart # 410021 for an outpatient surgery visit dated 5/30/2014.

The patient’s principal diagnosis was intractable epilepsy, unspecified (G40.911).

Additional reported diagnoses were not available, because no other abnormalities were found.

Services provided on the visit included replacement of a VNS generator for vagal nerve stimulator (61885).

~Angel Maldonado~

SC121: Human A & P I:

INSTRUCTIONS: Respond to all posts; response to classmates should be thoughtful and advance the discussion, response should make and/or frequent informed references to unit material or scientific literature, follow APA style if resources are used, 75 word minimum in response per post

CLASSMATE POST #2

For this week’s discussion, I chose to research Leukemia. I feel like I have the most basic understanding of what leukemia is, but I would like to understand it better. From my medical terminology class last term, I know that the word root leuk- means white and the suffix -emia means blood condition. Leukemia is a cancer of the blood and bone marrow in which the bone marrow produces abnormal white blood cells (hence the word root and suffix mentioned above). White blood cells in the bone marrow grow more rapidly which leads to overcrowding and replacement of normal cells (Freeman, 2017).

There are many different types of leukemia, but the most common symptoms include fever, chills, persistent fatigue and/or weakness, frequent infections, weight loss, swollen lymph nodes, enlarged liver or spleen, easy bleeding and/or bruising, nosebleeds, tiny red spots in your skin, night sweats, and bone pain (Mayo Clinic, 2018).

Luckily for a lot of leukemia survivors, they may not experience any long-term effects. However, there are possible effects that may not develop until years after treatment ends, such as heart disease or other cancers. Other effects of the disease that may occur later may be caused by treatment like chemotherapy rather than the disease itself. Those include chronic heart failure, heart muscle injury, thyroid problems, lung damage, infertility, osteoporosis, hearing loss, cataracts, secondary cancers, peripheral neuropathy, and/or impaired immune system function (Leukemia & Lymphoma Society, 2015).

Treatments for leukemia include chemotherapy which uses chemicals to kill leukemia cells; biological therapy which uses treatment that helps your immune system recognize and attack leukemia cells; targeted therapy which uses drugs that attack specific vulnerabilities within cancer cells; radiation therapy which uses x-rays to damage leukemia cells and stop their growth; and/or stem cell transplant which is used to replace diseased bone marrow with healthy bone marrow (Mayo Clinic, 2018).

After reading about the effects that chemotherapy can have, I think it could be very difficult to choose that sort of therapy to treat leukemia. I think maybe a stem cell transplant may be the least scary just because it does not use foreign materials to treat the disease, but rather healthy, naturally produced material.

~Abbie Boes~

CLASSMATE POST #3

Hello everyone,

The disorder I chose to write about for this discussion is Paget’s Disease. This disease typically affects the skull, spine, pelvis, femur, and tibia. This disease is chronic, and results in bones growing larger and becoming weaker than normal bone. This is because the new bone matrix is being built faster than it is being removed by the osteoclasts. The new bone doesn’t form correctly either, resulting in weaker, softer bone (National Institute of Health, n.d.).

Symptoms of this disease typically include; mis-shaped bones, bow shaped limbs, large head size, headaches, hearing loss, numbness and tingling in arms and legs, and hip pain. Long term affects include; joint cartilage damage, arthritis, heart disease, deformities, reduced blood flow to the brain and spinal cord, fractures, bone pain, and the loosing of teeth. However, there are many people don’t experience any symptoms with this disease (National Institute of Health, n.d.). This disease progresses slowly and in almost never seen in people under the age of 40. This disease is not known to cause cancer (National Organization for Rare Diseases, 2020).

Standard treatment for Paget’s Disease includes physical therapy to strengthen the muscles to control some of the pain. There are medications patients can take called bisphosphonates that reduce and suppress osteoblast reabsorption. Calcitoins are an injection, and this medication reduces bone turnover rate. Surgeries can be performed to fix fractures, and hip and knee replacements to relieve mechanical when patients are unresponsive to medication. Pain management therapies can be utilized as well (National Organization for Rare Diseases, 2020). Unfortunately, I couldn’t find any new therapies for Paget’s Disease other than what I already discussed.

-Angel