Nuance Clintegrity Physician Query
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