Scenario B (Questions 9-13): \"A 79-year-old woman was admitted with an acute ex
ID: 3515789 • Letter: S
Question
Scenario B (Questions 9-13): "A 79-year-old woman was admitted with an acute exacerbation of both Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD). She was appropriately treated for both conditions. The day after admission, an echocardiogram was done to determine the severity of the patient’s congestive heart failure. The echocardiogram indicated that the patient has both systolic and diastolic heart failure. Discharge diagnosis: Acute CHF exacerbation, COPD exacerbation." 9. What are the documented discharge diagnoses? Check all that apply: ?Acute exacerbation of CHF ?Systolic heart failure ?Acute exacerbation of COPD ?Diastolic heart failure 10. What additional information is documented about one of the diagnoses? (Check all that apply) ?Echocardiogram results ?CT scan ?Radiology report ?PET scan 11. Can the inpatient coder assign a code based on the echocardiogram report? ?Yes ?No 12. What information is missing? ?Additional scans ?Type of CHF ?History and physical report ?Discharge diagnosis 13. How can the coder obtain the missing information? ?Contact the patient ?Query the provider ?Add it to the report ?Search the patient records
Explanation / Answer
9. Documented diagnoses:
Acute exacerbation of CHF
Systolic heart failure
Acute exacerbation of COPD
Diastolic heart failure
Discharge diagnosis involves the conditions which need to be taken care of, after the discharge of the patient and also the condition for which the patient was treated.
10. Echocardiogram results
As only echocardiogram was performed on the patient, the results of echocardiogram is provided.
11. No
An inpatient coder cannot assign code based on echocardiogram report. He needs physician confirmation of the diagnosis.
12. History and physical report.
The physical report of the patient is required for the coder to code.
13. Query the provider
The coder needs to ask the provider all the necessary physical records of the patient in order to code.
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