Patient Presentation and Health Record Coding Paper

Guidelines for Final Project

Purpose: To assess student basic understanding of coding set related to patient presentation and health record

Students will be given a set of codes for ICD-10, CPT, and RxCUI. Students will need need to provide the following information

  • Code definitions: definitions should be simply stated.
  • Code descriptions and support: students should provide a detailed description of each code utilizing resources in the text, handouts, weblinks, and research. Appropriate inclusions and exclusions for the code need to be explored. Students should support the descriptions utilizing these resources. Accuracy of the descriptions and support will be vital (see grading rubric). Good academic writing style should be utilized in this section.
  • Patient story: Student may use descriptive, story-telling writing style to illustrate the codes. All of the codes need to be addressed in the illustration without misinterpretation and with good detail.

*For each case, you need to define the codes, provide a description for the codes, and create a short patient story that illustrates all the codes (1 patient story per case). You should set this up as a paper with each case taking up 1 to 1.5 pages. You can use the case as a Level I heading then have code definitions/descriptions and the patient story as Level II headings. The code definitions and descriptions need to be cited and referenced. Since this is a short paper, always include a title page and a reference page. In the rubric, you will notice that the majority of the points are in the code descriptions and the patient story sections – so spend the majority of your time in those two areas. At least 3 references (other than the course textbook) must be cited and referenced utilizing APA guidelines.



RxNav: in search bar, select RXCUI, then enter the code to find the medication. Medscape (you can register for a free account) can give you some idea of timing of the medication (every 12 hours, twice daily, once a day, etc)

CPT: Use the superbill coding sheet and google search. Do not pay for any source! A good resource may be

Case 1:

  • ICD-10: E78.2, F41.9, Z23
  • CPT: 99214, 36415, 90689
  • RxCUI 329212 and 2177394

Case 4:

  • ICD-10: Z00.11, Z23
  • CPT: 99381, 90748, 90700, 90680, 90713, 90670
  • RxCUI: 1007556, 1300188, 493191, 287617, 904641

Case 2:

  • ICD-10: F90.0
  • CPT: 99213
  • RxCUI: 687045

Case 5:

  • ICD-10: R04.0
  • CPT: 99203, 30901
  • RxCUI: 215051

Case 3:

  • ICD-10: L02.411
  • CPT: 99214, 10060
  • RxCUI: 315608

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