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

Answer 1

1. Yes. The patient is with Stage III pressure ulcer. In Stage III pressure ulcer, the ulcer can extend into the subcutaneous layer. This clearly shows the pressure ulcer is present on admission.  Because within two days, the pressure cannot be developed and progressed into stage III.

2. Yes. it indicates a postoperative complication. Around 1300cc amount of blood loss during surgery. The RBC level has been reduced because of this in the first postoperative day. This can be managed with effective treatment otherwise it leads to hypovolemia, shock, and even leads to death.

3. Chest X-ray is an important tool in diagnosing of pneumonia. Based on the diaphragmatic shadows and pulmonary consolidation, pneumonia can be identified. But the physician has to specify the type of pneumonia and the lobes involved. So that it can be coded accurately. Sometimes if it needs further investigation, it should not be included in the coding.

4. Documentation of BBB in progress note does not increase reimbursement at any cost. It compliance policies that interfere with organization and government agency.