Imagine that you are a health information management (HIM) supervisor analyzing a computer-assisted coding system to find out if it will work well for your facility. The following is an operative note Original Papers

Imagine that you are a health information management (HIM) supervisor analyzing a computer-assisted coding system to find out if it will work well for your facility. The following is an operative note with the ICD-10-PCS codes assigned by the computer-assisted coding (CAC) system that is being reviewed. Analyze the operative note and the accuracy of the code. If the code is incorrect, provide the correct code.

Operative Procedure: Excision mass of left little finger

Anesthesia: Local / Field Block

Procedure:

After satisfactory digital block anesthesia, with the patient being in the supine position, the left upper extremity was prepped and draped using Prevail and the usual draping technique, draping the left upper extremity free and supported on a hand table. A basal finger tourniquet was used. A zigzag incision was made over the volar aspect of the middle phalangeal area. Flaps were raised and the tissue was dissected. The neurovascular bundle was dissected, and there was some angiovascular tissue which was excised. The incision had to be enlarged as posterior to the neurovascular bundle was a thick sheet of tissue forming almost like a cord. It was partially attached to the tendon sheath over its radial aspect fairly close to the radial collateral ligament of the PIP joint. It was isolated and excised. Patient tolerated the procedure well and was sent to post-op recovery room in satisfactory condition.

ICD-10-PCS code assigned by the CAC: 0QBQXZZ

Is the assigned code correct? After reviewing the accuracy of the code assigned by the CAC, include the following in a one-page essay:

  • Discuss the pros and cons of using a CAC system versus having human coders assigning the codes for the facility.
  • Provide examples of errors that can occur when using the CAC system.
  • Discuss the role of coding professionals as auditors when working with a computer-assisted coding system.

Your essay must be at least two pages with at least one outside reference other than the course textbooks; at least one outside resource must come from the CSU Online Library. Adhere to APA Style when creating citations and references for this assignment.


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