Unit5MW

Morgan Wise HI253 Medical Coding I Unit 5 Assignment Worksheet Unit outcomes addressed in this Assignment:  Analyze a medical record for errors or omissions that require the creation of a physician query.  Develop appropriate physician queries to resolve data and coding discrepancies. Course outcome addressed in this Assignment: HI253-2.1: Recognize the information documented within a health record that leads to quality coding practices. AHIMA’s Professional Coding Approved Program (PCAP) Mapping: Domain I. Data Structure, Content and Information Governance I.4. Determine compliance of health record content within the health organization Domain IV. Revenue Cycle Management IV.1. Determine diagnosis and procedure codes and groupings according to official guidelines. IV.3. Evaluate compliance with regulatory requirements and reimbursement methodologies. ASSIGNMENT DETAILS Your coding manager asks you to review the case (#ED322223) for any coding discrepancies. You notice that additional information from the provider would allow you to code the diagnosis to a higher level of specificity. Your manager requests that you generate a physician query to resolve the issue. 1. Describe the deficiency that was present in the health record that would require a physician query to resolve. Record your response in the box below. 2. Refer to the Unit 5 Supplemental Readings “Guidelines for achieving a compliant query practice” and compose a written query to the physician to clarify the deficiency in the health record. Create and record your completed query in the box below. Submit the completed assignment worksheet to the Unit 5 Assignment Dropbox. CASE #ED322223 ED/ PROVIDER NOTE PCP: Medical Center Date of Arrival: 4/12/2014 Diagnosis: L AOM. Patient is very well-appearing and well-hydrated with no evidence of meningitis, mastoiditis, pneumonia, or other SBI. Disposition and Plan of Care: -Discharge home -Amoxicillin 620 mg PO BID x 10 days -Follow-up and return precautions as per ACI History of Present Illness: Source: Mother and sister CC: RN, congestion, and ear pain History of Present Illness: is a previously healthy 23 month old with tactile fever x 2 days with ear pain since 0300 this morning. +RN and congestion for the past two days. Taking less PO than usual, but urinating normally. No vomiting or diarrhea. No other concerns. Past Medical History: No prior hospitalizations No prior surgeries No ongoing medical conditions Family History: Negative for chronic childhood conditions Social History: Lives with parents and siblings Medications: Allergies: No Known Allergies Immunizations Status: up to date ROS: Constitutional: fever HEENT: RN, congestion, ear pain Respiratory: negative Cardiovascular: negative Gastrointestinal: negative Genitourinary: negative ROS (cont’d): Musculoskeletal: negative 2302B Unit 5 Assignment worksheet 1

Morgan Wise HI253 Medical Coding I Hematology/Lymphatic: negative Skin: negative Central Nervous: negative PE: Pulse 158 [crying] | Temp 98.2 | Resp 30 | Wt 15.3 kg, is alert, well developed, well nourished, in no acute distress HEAD : normocephalic and atraumatic EYES : pupils equal, round and reactive to light and extra-ocular movements intact EARS : R TM is normal appearing. L TM bulging and erythematous with purulent effusion NOSE : no discharge OROPHARYNX : mucous membranes moist with no oral lesions NECK: neck is supple with full active range of motion and no adenopathy CHEST : clear to auscultation bilaterally and no wheezes, rales, or rhonchi CARDIAC : regular rhythm, no murmurs and normal S1 and S2, no gallop ABDOMEN : nondistended, soft, nontender to palpation, no hepatosplenomegaly, no masses, no guarding or rebound tenderness and normoactive bowel sounds BACK : exam deferred GU : exam deferred EXTREMITIES : brisk capillary refill and no edema SKIN : no rashes and no petechiae Requirements: Your assignment should: • Have a cohesive viewpoint that is clearly established and sustained. • Follow the conventions of Standard English (correct grammar, punctuation, and spelling). • Be well ordered, logical and unified, as well as original and insightful. Unit 5 Assignment Chart Review & Physician Query Chart reviewed: #ED322223 1. Describe the deficiency that was present in the health record and would require a physician query to resolve: The diagnosis that was listed is left acute otitis media, L AOM. This is caused by a bacterial or viral infection that occurs in the middle ear. It can cause swelling, redness, fever, ear pain, and fluid/mucus to build up in the ear. This occurs more commonly in children. The right ear tympanic membrane appears normal, but the left ear membrane is bulging, erythematous, along with a purulent effusion. The doctor did not give enough specific information to probably code this information. 2. Compose a query to the physician to resolve the deficiency: Can you provide more information on the patient’s diagnosis? There is documentation that specifies that the L tympanic membrane was bulging and erythematous with a purulent effusion. This was not touched upon in the diagnosis. Can the diagnosis be further specified by the following: *Bilateral Acute Otitis Media *Left Otitis Media with Effusion *Left Acute Otitis Media *Right Acute Otitis Media *Other not listed (Please specify) Submitting your work: 2302B Unit 5 Assignment worksheet 2