Scenario C (Questions 14-17): \"A 30-year-old male was admitted with severe abdo

Question

Scenario C (Questions 14-17): "A 30-year-old male was admitted with severe abdominal pain and nausea. The patient has not experienced any vomiting. Because of the nausea, he was dehydrated and treated with IV fluids. The patient also has a history of Crohn’s disease. Abdominal X-rays were completed which showed significant inflammation in the sigmoid intestine. The attending physician did not document a causal relationship between the abdominal pain and the patient’s Crohn’s disease. Final diagnosis: Severe abdominal pain with nausea, dehydration and a history of Crohn’s disease.” 14. What are the documented discharge diagnoses? Check all that apply: ?Severe abdominal pain ?Nausea ?Dehydration ?History of Crohn's disease 15. What additional information is documented about one of the diagnoses? ?Blood test ?Ultrasound ?X-ray report ?EKG 16. Can the inpatient coder assign a code based on the x-ray report? ?Yes ?No 17. What missing information prevents the coder from coding to the highest degree of specificity? ?X-ray images ?Missing history and physical information ?Specification of X-ray type ?Relationship between the symptoms and the Crohn’s disease

Explanation / Answer

14.The document discharge diagnosis is severe abdominal pain with nausea.

15.Abdominal X-ray showed that there was inflammation in the sigmoid intestine is the additional information documennted.

16.The coding clinic has stated that in an inpatient setting coders cannot assign codes based on radiology report.

17.Coding from diagnostic report is based on physician documentation in the medical record.So the coder needs to take clarification before assigning a code for diagnosis.

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