HITM 1250 Case Study 1.15 (3)

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Anoka Technical College *

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1250

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Health Science

Date

Oct 30, 2023

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docx

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3

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1.15 Special health record documentation requirements Competency I.4 5 B G 5 1. You have been asked to audit a pediatric group’s medical records. In addition to verifying the appropriate E&M code assigned, you are tasked with ensuring that all relevant documentation is present in the record. a. Use the scenario and checklist that follow to determine if all relevant documentation is present in the record including discharge status. There is no discharge status listed. Even though the immunizations along with growth and development are listed under office notes dates, there are not any details for what types of vaccines were done along with what stage the growth and development is at. Just that it is appropriate and milestones are met. b. Verify the E&M code assigned. If the code is incorrect, select the appropriate code. Defend your selection whether you determine it is correct or incorrect. (10 points) The E/M code assigned is incorrect. It should be 99212 for an established patient with low level MDM.
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