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 Content, Structure & Standards (Information Governance)

Subdomain I.B. Health Record Content and Documentation

• 1. Analyze the documentation in the health record to ensure it supports the diagnosis and reflects the patient's progress, clinical findings, and discharge status (Bloom's Level 4)

oContent of health record

oDocumentation requirements of the health record

oHealth information media

Paper, computer, web-based document imaging

2. Verify the documentation in the health record is timely, complete, and accurate (Bloom's Level 4)

oDocumentation requirements of the health record for all record types

Acute, outpatient, LTC, rehab, behavioral health

Subdomain V.D. Clinical Documentation Improvement

1. Identify discrepancies between supporting documentation and coded data (Bloom's Level 3)

oClinical outcomes measures and monitoring

2. Develop appropriate physician queries to resolve data and coding discrepancies (Bloom's Level 6)

oAHIMA CDI toolbox

oProfessional communication skills

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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

ROS (cont'd):

Gastrointestinal: negative

Genitourinary: negative

Musculoskeletal: negative

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

ASSIGNMENT DETAILS

1.Your coding manager asks you to review the above 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.

2.Describe the deficiency that was present in the health record that would require a physician query to resolve.