Find-A-Note How to Use Code-A-Note 1. Access Find-A-Code from the AHIMA vLab. 2. Select the green Code-A-Note icon from the list of options. . 3. Now you are in the Code-A-Note Screen. Fill out the Patient information and enter your documentation into the Notes/EMR in the box on the left. 4. Select Scan Notes at the bottom of the screen. 5. Select the coding system tabs at the top right of the screen to check the codes and ensure they are applicable to the documentation. Make sure to select all tabs to check the codes for each coding system. MCCG240 EVALUATION AND MANAGEMENT SERVICES Computer Assisted Coding Audit Course, Program, and Institutional Outcome(s) Assessed: This assignment measures your ability to meet the follows outcome(s): · Course outcome: Synthesize results of aggregate coded data. · Program outcome: Analyze the results of aggregate coded data to report findings and trends. · Institutional outcome - Quantitative & Scientific Reasoning: Follow established methods of inquiry and mathematical reasoning to form conclusions and make decisions. Relevant Background Information: Coders often have additional job duties besides billing and coding. One of these duties is software evaluation. Because it is coders who use EHR software, encoders, or other health care software, they are often asked to evaluate software options prior to the administration making a purchase. Assignment Purpose: This assignment asks you to review code accuracy assigned from a computer assisted coding program to determine the benefits of using such a program in a medical office. Assignment Directions: Imagine that you are a coding supervisor and are tasked with finding a new encoder product. You have recommended that the administration consider purchasing an encoder that has computer assisted coding (CAC) because it would reduce the amount of time the coders need to code the physician’s documentation, thus encouraging a quicker reimbursement. You prefer Find-A-Code because of its Code-A-Note program. The administration has asked you to test out Code-A-Note within Find-A-Code and report your findings and a recommendation of whether or not to purchase this encoder. You want to base your review on the accuracy of Code-A-Note, so you decide to try coding three patient charts in the encoder to determine how accurate it is before making your recommendation. Follow the steps below to complete this assignment: 1. Review the following cases in your You Code It! textbook: a. Chapter 24: Olivia Fernandez b. Chapter 24: Lance Desimini c. Chapter 25: Peter Bartlett 2. Use your ICD-10-CM and CPT code books to identify all appropriate diagnosis, procedure, and E/M codes for each case. Record your answers in the provided Code-A-Note Review Notes template. 3. Now use the Code-A-Note feature in Find-A-Code to determine its level of accuracy. a. Notice that each case has been reproduced at the end of this document. This is to make ...

1. Find-A-Note
How to Use Code-A-Note
1. Access Find-A-Code from the AHIMA vLab.
2. Select the green Code-A-Note icon from the list of options.
.
3. Now you are in the Code-A-Note Screen. Fill out the Patient
information and enter your documentation into the Notes/EMR
in the box on the left.
4. Select Scan Notes at the bottom of the screen.
5. Select the coding system tabs at the top right of the screen to
check the codes and ensure they are applicable to the
documentation. Make sure to select all tabs to check the codes
for each coding system.
MCCG240 EVALUATION AND MANAGEMENT SERVICES

2. Computer Assisted Coding Audit
Course, Program, and Institutional Outcome(s) Assessed:
This assignment measures your ability to meet the follows
outcome(s):
· Course outcome: Synthesize results of aggregate coded data.
· Program outcome: Analyze the results of aggregate coded data
to report findings and trends.
· Institutional outcome - Quantitative & Scientific Reasoning:
Follow established methods of inquiry and mathematical
reasoning to form conclusions and make decisions.
Relevant Background Information:
Coders often have additional job duties besides billing and
coding. One of these duties is software evaluation. Because it
is coders who use EHR software, encoders, or other health care
software, they are often asked to evaluate software options prior
to the administration making a purchase.
Assignment Purpose:
This assignment asks you to review code accuracy assigned
from a computer assisted coding program to determine the
benefits of using such a program in a medical office.
Assignment Directions:
Imagine that you are a coding supervisor and are tasked with
finding a new encoder product. You have recommended that the
administration consider purchasing an encoder that has
computer assisted coding (CAC) because it would reduce the
amount of time the coders need to code the physician’s
documentation, thus encouraging a quicker reimbursement. You
prefer Find-A-Code because of its Code-A-Note program. The
administration has asked you to test out Code-A-Note within
Find-A-Code and report your findings and a recommendation of
whether or not to purchase this encoder.

3. You want to base your review on the accuracy of Code-A-Note,
so you decide to try coding three patient charts in the encoder to
determine how accurate it is before making your
recommendation.
Follow the steps below to complete this assignment:
1. Review the following cases in your You Code It! textbook:
a. Chapter 24: Olivia Fernandez
b. Chapter 24: Lance Desimini
c. Chapter 25: Peter Bartlett
2. Use your ICD-10-CM and CPT code books to identify all
appropriate diagnosis, procedure, and E/M codes for each case.
Record your answers in the provided Code-A-Note Review
Notes template.
3. Now use the Code-A-Note feature in Find-A-Code to
determine its level of accuracy.
a. Notice that each case has been reproduced at the end of this
document. This is to make it easier for you to copy the
documentation into the Code-A-Note.
b. Record your findings for each case in the provided Code-A-
Note Review Notes template.
c. Please see the How to Use Code-A-Note document in
Blackboard if you need additional directions on how to use
Code-A-Note.
4. If the codes provided by Code-A-Note are different than the
codes you identified using the code books, then provide
rationale to support your code choice(s). Record these
explanations in the provided Code-A-Note Review Notes
template.
5. In the same Word document, provide a three-five paragraph
(300-750 words) written recommendation of whether or not

4. Find-A-Code should be purchased. The written
recommendation should include the following parts:
a. A summary of the results of your encoder review: How
accurate was Code-A-Note? Include specific details that
reference the codes from the patient cases.
b. Notes on the ease of use of Code-A-Note. How easy or
difficult will this be to implement in your office? How easy or
difficult will it be to train coders on the use of Code-A-Note?
c. Your final recommendation: Should Find-A-Code be
purchased, and why?
6. Review the attached rubric to determine how your work will
be graded.
7. Submit your work by the designated due date.
MCCG240 Evaluation and Management Services
Computer Assisted Coding Audit
Rubric
Level 3
Level 2
Level 1
Level 0
50-42.5
42.49-35
34.9-32.5
32.49-0
Accuracy of code assignments
Student correctly assigned 85-100% (14-16) of the correct codes

5. in all 3 cases
Student correctly assigned 70-84% (12-13) of the correct codes
in all 3 cases
Student correctly assigned 65-69%(11) of the correct codes in
all 3 cases
Student correctly assigned 64% (10) or less of the correct codes
in all 3 cases
45-38.25
38.24-31.5
31.49-29.25
29.24-0
Recommendation
Student provides a written recommendation about the purchase
of Find-A-Code, which includes correct and thorough
explanations with numerous, specific details to the patient
cases.
Written recommendation meets or exceeds the minimum length
requirement (3-6 paragraphs or 300-900 words).
Student provides a written recommendation about the purchase
of Find-A-Code, which includes mostly correct and somewhat
thorough explanations with some details to the patient cases.
Written recommendation is at least two-thirds of the minimum
length requirement (2 paragraphs or 200 words).
Student provides a written recommendation about the purchase
of Find-A-Code, which includes somewhat correct explanations
with few details to the patient cases.
Written recommendation is at least one-third of the minimum
length requirement (1 paragraph or 100 words).
Student provides a written recommendation about the purchase
of Find-A-Code, which includes mostly incorrect explanations
with no details to the patient cases.

6. Written recommendation less than one-third of the minimum
length requirement (less than 1 paragraph or 100 words).
Or student did not provide a written recommendation.
5-4.5
4.49-3.5
3.49-3.25
3.24-0
Institutional Outcome
Quantitative & Scientific Reasoning:
Work indicates that the student has exceeded
expectations for this institutional outcome.
Quantitative & Scientific Reasoning:
Work indicates that the student has successfully
met expectations for this institutional outcome.
Quantitative & Scientific Reasoning:
Work indicates that the student has partially met
expectations for this institutional outcome.
Quantitative & Scientific Reasoning:
Work indicates that the student has not or scarcely
met expectations for this institutional outcome.
Final Score:
Comments:

7. Patient Cases
Chapter 24: Olivia Fernandez
WASSERMAN UROLOGY CENTER
233 STREAMLINE DRIVE • MAZE, FL 32811 • 407-555-6591
PATIENT:
FERNANDEZ, OLIVIA
ACCOUNT/EHR #:
FERNOL001
DATE:
07/16/18
Attending Physician:
Laverne Aspiras, MD
CLINICAL HISTORY: This patient, a 5-year-old Hispanic
female who had been previously healthy, was admitted to the
hospital 5 days ago with bloody diarrhea and dehydration. She
was treated with bowel rest and intravenous fluids. Her diarrhea
seemed to be improving; however, this morning she experienced
a prolonged generalized convulsion and she was transferred
emergently.

8. Upon arrival to the PICU, she appeared quite ill. She was
extremely irritable and quite pale. A blood coagulation test is
performed.
IMPRESSION: Hemolytic uremic syndrome caused by E. coli
H:0157.
PLAN: Dialysis is ordered.
Laverne Aspiras, MD
LA/pw D: 07/16/18 09:50:16 T: 07/18/18 12:55:01
Chapter 24: Lance Desimini
WASSERMAN UROLOGY CENTER
233 STREAMLINE DRIVE • MAZE, FL 32811 • 407-555-6591
PATIENT:
DESIMINI, LANCE
ACCOUNT/EHR #:
DESILA001
DATE:
12/03/18
Physician:
Sunil Kaladuwa, MD
This is a 7-year-old male who presents to the office with his
mother with a chief complaint of bedwetting twice a week.
Essentially he is healthy except for an occasional cough and
fever that the mother attributes to exposure to other children
with colds. Urinary discharge occurs at night only, and he
therefore has to wear diapers to bed. His mother is worried

9. since his brothers and sisters were all toilet trained by this age.
There is no history of dysuria, intermittent daytime wetness,
polyuria, or polydipsia.
PAST MEDICAL HISTORY: Unremarkable.
FAMILY HISTORY: Significant for his father being a
bedwetter. His child development is normal.
EXAM: VS T 37, P 110, R 20, BP 107/64, Ht 102 cm (25th
percentile), Wt 16.2 kg (25th percentile). He is alert and active,
in no distress. His appearance is nontoxic. HEENT and neck
exams are negative. His lungs are clear bilaterally. His heart has
a normal rate and rhythm, normal S1 and S2, and no murmurs or
rubs. No masses, organomegaly, or tenderness is appreciated on
exam of his abdomen. Bowel sounds are present. He has no
inguinal hernias. He has a circumcised penis of normal size.
The meatus is normally placed, without discharge. No phimosis
is present. His testes are descended bilaterally and are of normal
size (Tanner stage 1). His back is straight with normal posture
with no scoliosis or tenderness, or midline defects. His
extremities and muscle tone are normal. His gait is normal. His
speech and behavior are age-appropriate.
DX: Enuresis
PLAN: Mother is told that bladder control is usually attained
between the ages of 1 and 5 years and bedwetting becomes less
frequent with each passing year. I recommend that she be
supportive of her son’s dry nights and avoid criticism of wet
nights. I also recommend avoiding excessive fluid intake 2
hours before bedtime and emptying his bladder at bedtime.
Sunil Kaladuwa, MD
SK/mg D: 12/03/18 09:50:16 T: 12/06/18 12:55:01

10. Chapter 25: Peter Bartlett
ALTERNATIVE MEDICAL SERVICES
517 DIVERGENT WAY • HARRIS, FL 32811 • 407-555-9999
PATIENT:
BARTLETT, PETER
ACCOUNT/EHR #:
BARTPE001
DATE:
10/07/18
This patient is a 45-year-old male complaining of neck pain and
lower back pain that have become increasingly more difficult
since an MVA 2 weeks ago.
Patient states he was driving down Main Street and was struck
from behind by another driver. He states that the pain has been
constant since about 2 hours after the accident. He describes the
pain as pressure, “pulling, aching” in his neck and constant
aching in his lower back. The sharpness of the pain increases
with movement and subsides when he lies still. It is painful to
bend or walk. He said that he went to see his family physician,
Dr. Farina, last week, who referred him to our office.
X-rays: X-rays performed in office today: Cervical x-rays (PA-
Lat) show multiple subluxations of the cervical vertebrae with
pain on movement. Dens and spinous process are intact. No
breaks or fracture noted. Lumbar spine x-rays (PA-Lat) is intact
with no breaks or fractures.
TREATMENT PLAN: Spinal manipulations at neck and lower
back 2–3× per week for approximately 3 months, followed by
moist heat to release spasm and pain and increase circulation.
This will be followed by cryotherapy for the reduction of

11. swelling and pain. Ice/heat: prn.
PROGNOSIS: Good with no permanent impairment expected.
DIAGNOSIS: Cervical hyperflexion; subluxations of cervical
vertebrae C2-C5; lumbar sprain/strain, after two-car MVA.
Therapeutic treatments provided during this visit: Chiropractic
adjustment three to four regions; traction; hot/cold pack
therapy.
Natalie Crystalis, DC
NC/ml D: 10/07/18 11:47:39 T: 10/08/18 09:55:36
MCCG240 EVALUATION AND MANAGEMENT SERVICES
Computer Assisted Coding Audit
Code-A-Note Review Notes
Chapter 24 Olivia Fernandez
Code Books
Code-A-Note
Explanation of Differences
First Listed Diagnosis
Secondary Diagnosis

12. or Diagnoses
Principal Procedure
Secondary Procedure(s)
Code-A-Note Review Notes
Chapter 24 Lance Desimini
Code Books
Code-A-Note
Explanation of Differences
First Listed Diagnosis
Secondary Diagnosis
or Diagnoses

13. Principal Procedure
Secondary Procedure(s)
Code-A-Note Review Notes
Chapter 25 Peter Bartlett
Code Books
Code-A-Note
Explanation of Differences
First Listed Diagnosis
Secondary Diagnosis
or Diagnoses
Principal Procedure

14. Secondary Procedure(s)