In this Lab Activity, you will practice reading documentation in order to determine the following information:

1. Is the type of documentation for inpatient or outpatient services based on information in the documentation?
2. What are the diagnosis stated in the documentation?
3. What are the procedures stated in the documentation?
4. What coding systems will you use to code this documentation for both diagnosis codes and procedures codes?

A reminder:

Outpatient includes all physician services, emergency room services, outpatient surgical procedures, observation services in a hospital, and consultations by a physician.

Inpatient is only hospital services provided when a patient stays longer than 24 hours in the hospital.
(For further details please refer to the information given in your course.)

Here is an example of how to do this Lab Activity:

If the documentation is outpatient and I have two diagnosis documented and one procedure documented, I will be using ICD 10 CM for the diagnosis coding and CPT for the outpatient procedure coding.

If the documentation is inpatient and I have two diagnosis and two procedures documented I will use ICD 10 CM for the diagnosis coding and ICD 10 PCS for the inpatient procedure coding.

Lab Activity Instructions:

In a Word document create a Word Table with 5 columns across. Create the following headings in each column:

• Document Number
• Type of Service
• Diagnosis
• Procedure
• Coding Systems

• Use the five sets of documentation listed below and determine for each documentation the answer to each of the four questions given above. YOU WILL NOT BE CODING IN THIS LAB ACTIVITY.
• Read the documentation, determine the answers to the four questions, and place the answers to the four questions under the appropriate heading in your Word Table.
• You will only be determining the type of service (inpatient or outpatient), any diagnosis given, all procedures done, and which of the 3 coding systems you practiced in this course would you use to code the documentation.
• Complete your Word Document Table and submit it the drop box. (If you do not know how to create a table, call the Personal Support Center 24/7 call number found at the bottom of your course Home page.)
• Use the information in your code books to determine which service is coded inpatient and which will be coded using outpatient. Remember that ICD 10 CM diagnosis codes are used for both inpatient and outpatient coding.

HERE IS YOUR DOCUMENTATION TO USE FOR THIS LAB ACTIVITY:

1. The physician conducted a routine office visit and removed a lesion from the patient’s back by excision and repaired the excision with sutures. The lesion removed was a benign cyst.
2. A patient presented to the emergency room and tests revealed acute appendicitis with a rupture and abscess. The patient required surgery of an open appendectomy and required hospitalization and a two day hospital stay to prevent further infection.
3. A patient came into the emergency room and indications were suspect for a possible TIA or transient ischemic attack. He also was found to have hypertension and hyperlipidemia. No treatment was given as the TIA symptoms had resolved and the patient was released.
4. A patient was ordered by his physician after an office visit to be admitted to the hospital for acute recurring pancreatitis. While in the hospital he was also found to have gallstones and the surgeon performed a cholecystectomy to remove the gallbladder. He was hospitalized for three days.
5. A morbidly obese patient with a BMI of 48.2 requested gastric bypass surgery. This surgery was performed in an Ambulatory Surgical Center where he was released the same day after a successful surgery.