cloynes_module02codingassignmentbethlongchart_011224

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Rasmussen College *

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2944

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Mechanical Engineering

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Feb 20, 2024

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Directions: The purpose of this assignment is for you to exhibit your critical thinking skills by coding the medical chart. You are also required to complete the assignment by using the 3M encoder. Provide a screenshot from 3M of your work for questions 1 and 5. Your professor will evaluate your answers for coding guideline usage, communication from individual perspective, coding abstraction, sequencing and 3M encoder usage. Please provide all answers in the appropriate boxes listed below the questions. 1. What is the principal diagnosis? What pathway did you take in order to code the condition properly? Please provide a screen shot of encoder usage for your answer. Acute Pyelonephritis 2. Given that you’ve provided the correct answer for question #1. Please list the instructional note listed in the tabular list to help support the ICD-10-CM code in question #1? Provide an explanation of why you feel the code listed for the principal diagnosis is appropriate. Acute Pyelonephritis is inflammation of the kidneys due to a UTI; the kidneys are a part of the Genitourinary system. The tabular list states that additional codes B95-B97 are needed to identify infectious agents. 3. In the History and Physical the patient complains of left upper flank pain should this condition be coded? What coding guideline supports your decision? Explain. No, coding guideline B5 states that signs and symptoms that are associated with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. 4. In the family history section of the history and physical the physician documents, “she has a brother with mild epilepsy” should this be coded why or why not? Explain.
No, her brother having mild epilepsy doesn’t need to be coded because it’s not the reason for her sickness. 5. Given that the principal diagnosis is listed for question #1, please list all secondary diagnoses and the pathways. Please list all appropriate codes and give the proper sequence of the codes listed. Please provide a screenshot of encoder usage for your answer. Secondary Diagnoses & Pathway: Escherichia coli-B92.20 Dehydration- E86.0
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