Question

Case 5.15 Query Analysis (20 points)

Review the following Queries and determine if they are acceptable physician queries. Give the reason for your decision for each case.

1. Dr. Hightower

Mrs. Smith was admitted on 8/25, and two days later you mention in a progress note a stage three pressure ulcer of her heel that you debrided at the bedside. Can you clarify was the stage three heel pressure ulcer present on admission?_____Yes_____No

C. Coder 9/2 Ext. 2112

2. Patient name: Susan Stokes MRN: 1064532 Dates of service: 09/27/2016 - 09/30/2016

Dr. Ming Jun

The operative report indicates that 1300 cc of blood was lost. A CBC on the first POD shows a low RBC. Does this indicate a postoperative complication?

Coder Bob

3.  Patient name: Tim Smith MRN: 1074567 Dates of service: 09/27/2016 - 09/30/2016

Dr. John Day

Please add pneumonia as indicated in the CXR.

Coder: Doe

4.   Patient name: Margaret Brown MRN: 10897432 Dates of service: 09/27/2016 - 09/30/2016

Dr. Elizabeth Moore

If you will document the BBB in the progress notes we can increase reimbursement.

Coder: Peter

Please provide accurate answers and detailed rationale for each answer. Thank you ( :

Answer 1

1. Yes. Stage III pressure ulcer present on admission. Because within two days, the pressure cannot be developed and progressed into stage III.

2. Yes. it indicates a postoperative complication. More amount of blood lost during surgery and RBC reduced as a result of this. This leads to hypovolemia, shock, and even leads to death.