The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck

Question

The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck

Edition 1ISBN: 978-0323430777

The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck

Edition 1ISBN: 978-0323430777

Exercise 2

1-1B DISCHARGE SUMMARY __________________________________________
Professional Services: 99238 (Evaluation and Management, Hospital, Discharge)
ICD-10-CM DX: E10.10 (Diabetes, type 1, with, ketoacidosis), E86.0 (Dehydration),
J45.909 (Asthma)

Explanation

Verified

The hospital discharge services are based on the time the physician spends in the final discharge of the patient. The service may or may not include an examination of the patient. Since the physician did not indicate the time spent in discharge of the patient, the low-est level of discharge is reported (99238). Physician education is very important to ensure appropriate reimbursement, since only if the physician records the amount of time can the coder accurately assign a discharge code for a higher level discharge service. The time must be docu-mented in the medical record with the beginning and ending time and the time does not have to be consecutive. The physician may spend time on preparation of the final discharge and then return and spend additional time on the discharge documentation.
The diagnoses are diabetes, dehydration, and asthma, as indicated in the Discharge Diagnosis section of the report. Nausea and vomiting (R11.2) are integral to the disease process (symptoms) and not reported separately. The dehydration is reported separately as it is a dis-tinct condition.