The attending physician did not document a causal

  • No School
  • AA 1
  • 5

This preview shows page 3 - 5 out of 5 pages.

inflammation in the sigmoid intestine. The attending physician did not document a causal relationship between the abdominal pain and the patient’s Crohn’s disease. Final diagnosis: Severe abdominal pain with nausea, dehydration and a history of Crohn’s disease.” 14. What are the documented discharge diagnoses? Check all that apply: X Severe abdominal pain Nausea X Dehydration X History of Crohn's disease 15. What additional information is documented about one of the diagnoses? Blood test Ultrasound X X-ray report EKG 16. Can the inpatient coder assign a code based on the x-ray report ? Yes X No 17. What missing information prevents the coder from coding to the highest degree of specificity? X-ray images Missing history and physical information Specification of X-ray type X Relationship between the symptoms and the Crohn’s disease Scenario D (Questions 18-20): "A 75-year-old gentleman was admitted for control of his atrial fibrillation. Two days after admission the attending physician documented the presence of a decubitus ulcer on the buttocks. After thorough review of the health record, the nursing intake documentation did identify the presence of the decubitus ulcer and stated it was stage II. Final diagnosis: Atrial fibrillation with decubitus ulcer on buttocks." 18. What were the documented final diagnoses? Check all that apply: Stage II X Atrial fibrillation X Decubitus ulcer buttocks Nausea 1803A Unit 10 Assignment #1 Worksheet 3 false false
Image of page 3
HI253 Medical Coding I 19. What information is documented about one of the diagnoses and is needed for accurate coding? Check all that apply: Location X Size Stage Treatment 20. Can the inpatient coder assign a code based on the nurse’s documentation ? Yes X No Scenario E (Questions 21-24): "A 79-year-old female was admitted with acute shortness of breath and the patient also carries a diagnosis of CHF and COPD. The emergency room physician suspected pneumonia but this was ruled out. The consulting physician felt that the patient’s symptoms were ‘more heart failure related’; however, the progress note on 7/9/09 at 0830 hours by the attending physician noted that he did not feel the shortness of breath was related to congestive heart failure due to lack of clinical findings. The final progress note on 7/9 by the Heart Failure Clinic states that the shortness of breath was due to volume overload.” 21. What were the documented diagnoses? Check all that apply:
Image of page 4
Image of page 5

You've reached the end of your free preview.

Want to read all 5 pages?

  • Fall '19
  • shortness of breath, attending physician, Crohn's disease

What students are saying

  • Left Quote Icon

    As a current student on this bumpy collegiate pathway, I stumbled upon Course Hero, where I can find study resources for nearly all my courses, get online help from tutors 24/7, and even share my old projects, papers, and lecture notes with other students.

    Student Picture

    Kiran Temple University Fox School of Business ‘17, Course Hero Intern

  • Left Quote Icon

    I cannot even describe how much Course Hero helped me this summer. It’s truly become something I can always rely on and help me. In the end, I was not only able to survive summer classes, but I was able to thrive thanks to Course Hero.

    Student Picture

    Dana University of Pennsylvania ‘17, Course Hero Intern

  • Left Quote Icon

    The ability to access any university’s resources through Course Hero proved invaluable in my case. I was behind on Tulane coursework and actually used UCLA’s materials to help me move forward and get everything together on time.

    Student Picture

    Jill Tulane University ‘16, Course Hero Intern

Stuck? We have tutors online 24/7 who can help you get unstuck.
A+ icon
Ask Expert Tutors You can ask You can ask You can ask (will expire )
Answers in as fast as 15 minutes
A+ icon
Ask Expert Tutors