Part I: Read the Project 4 Case scenario Operative Report. Research the format of Operative
Report. Provide the missing/necessary requirements of an Operative Report using Project 4
Case Scenario. Read the Operative Report and use online search engines to provide the
definition of clinical vocabularies, illustrations / diagrams of surgical equipment / supplies and
meaning of Medical Terms used. Review the Operative Report to identify the documentation
supporting the diagnosis and the procedure. Assign the correct ICD-10-CM diagnostic code(s)
and ICD-10-PCS procedural code(s) using both coding manuals. Indicate the principal
diagnosis, comorbid conditions, complication (if any). Use the CMS website to identify the DRG
weight, MDC, Title, ALOS, and GLOS. Explain the process of choosing the DRG.
Part II: Compare the coded data submitted by provider with your answer in Part I. Enumerate
the discrepancies between the coded data and supporting documentation. Provide
AH1005
Fall, 2021
Semester Lab Project 4 CDI
2
recommendations to address issues of discrepancies; create / design appropriate physician
query for this case.
Part III: This report must be typed in Times New Roman, size 12 font, doublespaced and
approximately 2-3 pages in length. It must include: the impact of DRG to patient’s quality of care
and reimbursement, impact of documentation to coding quality and assigning principal
diagnosis.
