Computer-assisted coding Exercise

2.  Computer-assisted coding Exercise 

Read the following excerpt from a patient record that has been processed with computer-assisted coding (CAC) software.  

1.  Determine any areas of inaccuracy in the CAC identification

2.  Recommend corrections to the code assignment

Mr. Reynolds is a 57-year-old white male admitted with chest pain.  He developed this pain while shoveling snow outside his home.  He ranks it as an 8 out of 10 on the pain scale.  He has no arm or jaw pain.  He has hyperlipidemia, and hypertension, on medication for both conditions.  Last year he suffered an acute myocardial infarction and was treated with stents.  An EKG was performed, and cardiac enzymes are drawn.  All results were normal.  The patient exhibited pain upon movement and palpitation at the chondrosternal joint and a final diagnosis of sprain was determined.

Codes assigned by CAC:

R07.9

I21.3

R68.84

S23.421

I10

E78.5

3.  CAC and Fraud Detection 

As a coding supervisor, you would like to see computer-assisted coding (CAC) implemented in your organization.  You recognize that you will have to convince the administration of the merit of investing in this technology that goes beyond coding.  Knowing that compliance has been a major focus of the organization, write a memo to the chief financial officer, Ms. Moneybags, which proposes the use of CAC to assist with fraud detection and prevention.