Reference no: EM133566281

1. The discharge summary states the following diagnoses. Select ALL diagnoses that should be coded.

You must take into account guidelines we have studied pertaining to signs and symptoms, and coding for previous conditions that do not effect the current stay. (If I had not given you the above additional information, you would need to think about and consider this on your own. This is called critical thinking which is determining the answer based on what you know to be accurate based on what you have studied).

Question 25 options:

acute pancreatitis

status post umbilical hernia

abdominal pain

GERD
2. An 80-year old patient is admitted with a broken femur due to a fall. The attending physician plans an ORIF procedure after consulting with the patient's cardiologists. The cardiologist states the patient's chronic diastolic CHF is stable, and he will continue the Diltiazem medication while hospitalized. The patient was discharged 5 days after the procedure to the inpatient rehab facility. The diagnosis listed on the discharge summary by the attending physician is Fracture of neck of right femur. What diagnosis(es) should be coded? DO NOT code the diagnosis(es) from the codebook. Write the name of diagnosis(es) that should be code in the blank provided.

 

3. A 69-year-old female admitted to the hospital with abdominal pain. The past history noted in the medical record indicates the patient has COPD that has been monitored throughout the hospital stay. On day 2 of the admission, the patient experiences an acute exacerbation of the COPD and is put on oxygen. The diagnoses listed on the discharge summary were abdominal pain and COPD with acute exacerbation. Which would be the correct POA indicator that should be assigned to the diagnosis of COPD with an acute exacerbation when coding this scenario? Type the correct answer? (Yes, No, Unknown, or clinically undetermined)

 

4. Read the scenario below and identify the principal diagnosis. This scenario is NOT to be coded, but rather write out the correct principal diagnosis.

The patient is admitted with severe abdominal pain in the right lower quadrant, and an admitting diagnosis of probable acute appendicitis. The WBC count is slightly elevated. The patient is taken to surgery, where a normal appendix is found but an inflamed Meckel's diverticulum is removed. What is the principal diagnosis?

 

5. The patient presents to the physician's office complaining of chest pain. After examination the physician's diagnosis is suspected angina. The patient is sent for an EKG and is to report back to the physician the next day. What should be the first-listed diagnosis?

 

6. Read the scenario below and identify the first-listed diagnosis. This scenario is NOT to be coded. Write out the first-listed diagnosis.

Patient presents to the hospital's outpatient surgery center for a scheduled cholecystectomy for cholecystitis. Before the surgery began, the patient started experiencing malignant hypertension and the surgery was postponed. What should be the first-listed diagnosis?

 

7. A patient is admitted with acute myocardial infarction. The patient was administered nitroglycerin for chest pain, and sent for an echo to determine the extent of the MI. On day three of the admission in the progress notes, the physician notes the patient has an ingrown toenail, and a bunion on the right foot. Final discharge diagnoses are: Acute MI, ingrown toenail, and bunion. Identify the diagnosis(es) that should be coded for this inpatient stay.

Question 31 options:

All diagnoses of acute MI, ingrown toenail, and bunion should be coded

Only the acute MI and ingrown toenail

Only the ingrown toenail and bunion

Only the acute MI should be coded
8. Patient is admitted with type 2 diabetes. An A1C blood test was ordered and the patient was started on a higher dose of Metformin, BID. The physician also orders a urine culture and discovers the patient's creatinine levels are exceedingly above the normal range. the patient is known to have CKD stage 3. What would be the correct code(s) based on the documentation provided? Look up the diagnosis(es) in your code book and provide the correct code(s) based on how this scenario should be coded.

9. A patient is admitted with severe chest pain. The physician orders an EKG to determine possible heart disease. After further work up, and upon discharge, the physician documents suspected CAD. What diagnosis(es) should be coded? Write the diagnosis(es) and DO NOT code from the code book.

10. Patient was admitted with severe abdominal pain in the upper right quadrant. A X-ray was ordered, due to the physician's suspicion of the patient having constipation which is part of the patient's history, to rule out constipation. The X-Ray was negative and constipation was ruled out as the reason for the abdominal pain. What would be the principal diagnosis? DO NOT code from the codebook, but rather write the principal diagnosis. When writing the diagnosis, please make sure you are writing the diagnosis to the highest specificity that could be coded if you were going to code the diagnosis you writing.

11. 34-year-old presents to the ER with a 3-day history of stomach pain, nausea and vomiting and diarrhea. The physician suspected the patient of having food poisoning. DO NOT code the diagnosis(es) that should be listed, but write the diagnosis(es) in the space provided.

12. 57-year-old seen in the physician's office with fever and chills, rule out pneumonia. Patient will return tomorrow for a chest x-ray. DO NOT code the diagnosis(es) that should be listed, but write the diagnosis(es) in the blank provided.