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My Coding Coach 1

Caution!!! You are entering the knowledge portal. Only proceed if you are prepared to expand your clinical knowledge and grasp of complex scenarios. No coding books are required for the flashcard quiz bank. 2

Question: The physician is planning to perform a complete colonoscopy but the scope is withdrawn from the rectum after only visualizing the patient s intestine to the sigmoid flexure. What is the rule regarding coding of endoscopic procedures that are not performed as planned? 3

Answer: Code the service as far as it was performed. 4

Question: When an admission is for the management of dehydration due to malignancy or therapy and only dehydration is being treated, what will be the first listed diagnosis? 5

Answer: Dehydration Did you know: Dehydration is a serious condition requiring immediate medical attention! 6

Question: When admission is for treatment of a complication resulting from a surgical procedure and the treatment is directed at resolving the complication what should be the first listed or Principal diagnosis? 7

Answer: The complication 8

Question: A patient was admitted with acute on chronic systolic and diastolic congestive heart failure. Per the coding guidelines, what will be the first listed diagnosis? 9

Answer: The code for the acute on chronic diastolic and systolic condition. 10

Answer: Angioplasty services My Coding Coach Note: Angioplasty may be performed without stent insertion. A stent insertion may not be performed without the angioplasty! Copyright (c) My Coding Coach All Rights Reserved 2014 12

Question: Per the coding guidelines, why wouldn t hypoxia be coded in a patient who has acute respiratory failure? 15

Question: A patient reports to the outpatient surgery department for an arthroscopic meniscectomy for a torn meniscus. The patient is prepped by Anesthesiologist and is found to be in atrial fibrillation. The surgeon decides not to proceed with the procedure. What will the principal diagnosis be? Copyright (c) My Coding Coach All Rights Reserved 2014 17

Question: A patient is admitted with burns on bilateral lower legs documented as second and third degree. Based on this documentation, what is the principal diagnosis? 19

Answer: The 3 rd degree burn of the legs as that is the highest degree of burn listed. 20

Question: You are the coder on a case where there is documentation a UTI is present. You review the labs and find that >100,000 flora of E coli are present. There is no physician documentation of the organisms presence. May the code for the bacterial infection be coded in conjunction to the UTI? 21

Answer: No, coders are not allowed to code from lab reports. This is an opportunity to query to enhance the data quality of the coding. 22

Question: You are the coder on a case indicating a patient is in the hospital with a fractured femur. The physician does not indicate the exact site on the femur involved in the fracture. What resource may you use in determining where the exact fracture location? 23

Answer: The radiology report Anywhere Hospital USA Radiology Report: Views of the right leg demonstrate an acute fracture at the mid shaft of the femur. Clinical correlation for vascular or neurological disruption is warranted. Electronic Authentication: Stanley Rontgen, MD 24

Question: A patient in the ER is noted to have SOB that is documented as being due to an URI or COPD. What will the first listed diagnosis in this case? Copyright (c) My Coding Coach All Rights Reserved 2014 25

Answer: Shortness of breath because the patient presented with a symptom followed by comparative and/or contrasting diagnoses. Per the coding guidelines, the symptom will be listed first in this instance followed by the codes for the comparative/contrasting diagnoses. Copyright (c) My Coding Coach All Rights Reserved 2014 26