Nuance Clintegrity Physician Query

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What are the discharge diagnoses documented in the scenario? Check all that apply.

Pneumococcal pneumonia back pain

How can the coder obtain the missing information?

Query the provider

How can the encoder obtain the missing information?

Query the provider

How can the coder obtain the missing information

Query the provider.

If so, what information?

Radiology report

What missing information prevents the coder from coding to the highest degree of specificity?

Relationship between the symptoms and the Crohn's disease

One of the diagnoses is a symptom. Which one?

SOB

What are the documented discharge diagnoses? Check all that apply.

Severe abdominal pain nausea dehydration history of crohn's disease

What missing information prevents the inpatient coder from coding to the highest level of specificity? Check all that apply.

Underlying cause of SOB Underlying cause of volume overload.

What additional information is documented about one of the diagnoses?

X-ray report

Does the record contain additional information about that condition?

Yes

What were the documented diagnoses? Check all that apply.

acute SOB CHF COPD

If so, which diagnosis?

back pain

What additional information is documented?

echocardiogram

What additional information is documented about one of the diagnoses?

echocardiogram results

What additional information is documented about one of the diagnoses? Check all that apply.

location stage

Can inpatient coders assign codes based on a radiology report?

no

Can the inpatient coder assign a code based on the x-ray report?

no

Can the inpatient coder code from the echocardiography report?

no

How can the coder obtain the missing information?

query the provider

What missing information prevents the coder from coding to the highest level of specificity?

relationship between SOB and CHF

What information is missing?

type of CHF

What information is missing?

underlying cause of the back pain.

Can the inpatient coder assign a code based on the nurse's documentation?

yes

Is any diagnosis a symptom whose underlying cause may have been confirmed but not documented?

yes

Part 2 What are the documented discharge diagnoses? Check all that apply.

Acute exacerbation of CHF Acute exacerbation of COPD

What were the documented final diagnoses? Check all that apply.

Atrial fibrillation Decubitus ulcer buttocks

Can the inpatient coder assign a code based on the echocardiogram report?

NO


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