Proper Coding Assignment

of Anesthesia and Pain

Management Accounts
Carla Pratt
HCMT 2030
 The final practicum project is a requirement of all students
enrolled in the Health Information Systems program at the
University of Cincinnati. To fulfill this requirement I spent 40 hours
Introduction of on-sight experience at the Cincinnati Childrens Hospital.
I had the pleasure of completing my practicum in the Anesthesia
Coding Department under direct supervision of the coding
supervisor, Shawn Muench, CPC, CANPC.
 To gain knowledge of proper coding practices and coding
assignment by coding actual patient accounts for the anesthesia
Goal and pain management department.

Statement By reviewing patients operative reports, assigning the

appropriate diagnosis codes and CPT codes, and receiving
feedback from the project supervisor about coding accuracy.
 To review patients operative reports located in Epic and
extracting pertinent medical information.
To assign proper diagnosis and CPT codes based on the medical
Project Scope information extracted from the operative report.
To complete coding assignments within a reasonable amount of
time in order to receive feedback from the coding supervisor.
 The project will last approximately 4 weeks, and at the end of each
week the site supervisor will be given a completed spreadsheet of
all coding assignments completed by the student. The student will
Deliverables receive the completed spreadsheets back with feedback. At the
completion of the project a formal presentation will be presented
to the site supervisor and the students peers.
 Coding Supervisor
Certified Coders
Desktop Computer
EPIC
Operative Reports
ICD-10-CM Professional for Physicians
Resources CPT 2017 Professional
ICD-10DATA.com
3M
Master Daily Schedule of Patient Accounts
Chart to Imaging Reference Sheet
 Assigning the incorrect diagnosis or CPT code
Missing medical records
Canceled procedures
Project Risks System and power outages
Random audits
Lack of available desk space
Project Task
Outline
 10/02/2017-10/03/2017:
Emailed site supervisor and discussed days and times I would be in the
anesthesia department for the practicum.

10/23/2017 10/27/2017:
Met with site supervisor and went over project expectations.
Discussed functions of the anesthesia coding department.
Received spreadsheet of patient accounts I would be coding.
Coded one account with the site supervisor and the rest were coded by myself.
Turned in accounts that were coded to the site supervisor.

10/30/2017 11/03/2017:

Project Met with site supervisor and received feedback regarding the accounts I coded
the previous week.
Received a new spreadsheet of coding assignments to be completed.

Timeline Sat with a coder and went over her coding techniques.
Entered anesthesia charges into EPIC

11/06/2017 11/10/2017:
Met with site supervisor to go over this weeks tasks.
Finished coding spreadsheet I received the previous week.
Coded MRI accounts.
Received a new coding spreadsheet as well as another MRI spreadsheet.

11/13/2017:
Met with site supervisor and discussed final project and reviewing PowerPoint
presentation.
Finished coding MRI accounts and surgical accounts spreadsheet.
Went over previous spreadsheets I coded.
 There is no set productivity standard for the anesthesia coding
department.
Departments goal is to code for every department by the end of
Department the day.
Processes Cincinnati Childrens strives for a 95 percent accurate coding rate.
Audits are performed randomly by Cincinnati Childrens own
auditing team.
 The project lasted a total of three weeks in which I coded several
patient accounts for the anesthesia an pain management
department. I made the most coding errors during the first week
but improved during the second and third week.
Project The coding supervisor offered suggestions to cut the amount of
time coding by making a list of codes that are used frequently so I
Summary wouldnt have to keep looking them up.
Overall I felt I was provided with a lot of helpful information and
gained some valuable coding experience that I can take with me in
the future.