Review Clinical Documentation Assignment Help: How to Answer This Question

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Original Question

Review the clinical documentation in the cases provided below. For this assignment you are auditing the coding for the physician’s work in the outpatient setting (surgery, office visit, or ED). Procedures documented but not done by the physician are not a part of this audit. Review the provided ICD-10-CM and CPT code(s). Determine per coding guidelines if the codes listed are correct. Determine per coding guidelines and the provided clinical documentation if there are any missing codes or modifiers (if warranted). Provide your audit information (per below submission format) for all cases of this assignment beginning on page 2 of this document. Case 1 Do you agree with all the assigned ICD-10-CM code(s)? (answer is Yes or No) If not, what ICD-10-CM codes would you assign? (list out the codes you would assign and why) Do you have any CPT procedure codes to add? (The answer is Yes or No; remember you are auditing for the physician work, not for work done by radiology tech or pathology department) If so, what? (list out the CPT code(s) you would assign and why) Do you have any concerns/issues for a physician query? (list out the concerns or issues you would query) Cases of this Assignment Case 1 – Patient Malcolm Queen 39-year-old male – ED Visit documentation History of present illness: The patient is a 39-year-old African-American male who has sickle cell anemia. He was seen in the hospital ED two days ago, with diffuse extremity pains with minor complaints of pain along the right inguinal area. He was treated in the ED two days again and then discharged to home. In the last 24 hours, the pain has started again. Today, he is back in the ED. He denies any problems with cough or sputum or production. He denies any problems with a fever. Past Medical History: See recent medical records in charts. He does have a new onset of diabetes, probably related to his hemochromatosis. He does have evidence of iron overload with high ferritins. Review of Systems: Otherwise unremarkable except for those related to his pain. He denies any problems with fever or night sweats. No cough or sputum production. Denies any changes in GI or GU habits. No blood from the rectum or in the urine. Physical Examination: This is a 39-year-old male, who is conscious and cooperative. He is oriented x 3 and appears in slight distress. Vital signs are stable. HEENT is remarkable for icterus present in oral mucosa and conjunctivae, which is a chronic event for him. The neck is supple. No evidence of any gross lymphadenopathy of the cervical, supraclavicular, or axillary areas. The heart is abnormally irregular in rate without any murmurs heard. Lungs are clear to auscultation and percussion. The abdomen is soft and benign without any gross organomegaly. Extremities reveal no edema. No palpable cords. He does have some tenderness along the inner aspects of the right lower extremity near the inguinal area; however, no masses were palpable. The patient was treated for his painful sickle cell crisis with IV fluids and pain medications. He had a problem with his right inguinal area. He had evidence of pain. There was pain on the abduction of his right lower extremity. There was no evidence of any Holman; no palpable cords, no masses were palpable. Because of his sickle cell anemia, rule out the possibility of osteonecrosis due to hemoglobinopathy of the right femur. Complete x-rays of his femur and hip were carried out by the radiology department. However, per the report, these were both negative. The patient will be discharged from the ED with outpatient follow-up. Diagnoses: Sickle cell crisis, diabetes mellitus type 2, chronic atrial fibrillation Signed: Dr. Malcolm Plainfield Codes Assigned: D57.219, I48.1, E11.9, D58.2, M90.551 Do you agree? If not, what codes would you assign? (Remember missing codes should be included if warranted by your audit findings).

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