Length of stay 6 days.
Identify the portion of the medical record in which the following statements would MOST likely be found.
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Q. 2) Which of the following is a confirmatory document for coders?
A. HPI
B. Physical examination
C. Discharge summary
D. Physical therapy report
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Q. 3) Which of the following should NOT be coded for the physician's office?
A. Rule out MI
B. Chronic bronchitis
C. Generalized fatigue
D. Late effect of CVA
(
Q. 4) _________ The left kidney has a slightly irregular configuration and is not as well visualized as the right.
Fill in the blank with correct word.
(
Q. 5) INDICATIONS: 55-year-old male with episodic abdominal pain for almost a year. Recurrence of the pain ultimately led to cholecystectomy in 890. Periodically the pain has been severe enough that he goes to the emergency room. I have seen him in the past for left upper quadrant pain, which I felt, was due to irritable bowel syndrome. Four days ago, he had an episode of severe epigastric pain that seemed to radiate up into his chest and at times his neck. He described the pain as burning. It lasted a few hours and then resolved. Last night the pain recurred and was extremely severe. He was taken to the emergency room where he required parenteral narcotics.
PROCEDURE: Following informed consent , he was sedated with Demerol 40 mg and Versed 1 mg IV. Oropharyngeal anesthesia with Cetacaine spray was administered. An Olympus OES type GIF-XQlO endoscope was introduced. The esophagus was unremarkable. The z-line was at 40 cm. from the incisors. There was no endoscopic esophagitis. No hiatal hernia was seen. Retroflex exam of the fundus and cardia was unrevealing. Pylorus , duodenal bulb, and several centimeters of post-bulbar duodenum were also unremarkable. The ampulla of Vater was seen tangentially and normal. He tolerated the procedure well. Two biopsies were taken of the distal esophagus to look for histologic evidence of inflammation.
IMPRESSION: Normal esophagogastroduodenoscopy. Wonder if he is having panic attacks. He does describe some symptoms of gastroesophageal reflux disease and irritable bowel syndrome as noted above.
PLAN: He will be discharged to home and will remain on Zantac 105 mg po bid. I will notify him with the biopsy reports. He will try Xanax 0.5 mg po at the onset of pain in the future. He is aware that this may cause sedation and that he should be careful around moving vehicles.
ICD-9-CM diagnosis code(s): _____________________
_____________________________
_____________________
ICD-10-CM diagnosis code(s): _____________________
_____________________________
_____________________
CPT code(s) with modifier, if applicable: _____________________
What will be an ideal response?
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Q. 6) _____ orders may address specifically artificial breathing or cardiopulmonary resuscitation and extend to pain control and nutrition.
A. Restraint
B. DNR
C. Standing
D. Discharge
(
Q. 7) _________ She denies ear pain and no nausea or vomiting.
Fill in the blank with correct word.
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Q. 8) _________ Significant for colon malignancy of her father , as well as some hypertension.
Fill in the blank with correct word.
(
Q. 9) The patient's principal diagnosis, secondary diagnoses, principal procedure, and secondary procedures and disposition of the patient are documented in the _______.
A. face sheet
B. clinical information
C. abstract summary
D. discharge summary
(
Q. 10) The UHDDS defines _______ as one which is surgical in nature, carries a procedural risk, carries an anesthetic risk, and/or impacts MS-DRG assignment.
A. significant procedure
B. principal procedure
C. POA indicator
D. principal diagnosis
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