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Medical Insurance 7th Edition by Amy Blochowiak, Joanne Valerius, Nenna Bayes, Cynthia Newby
Edition 7ISBN: 978-1259683077Medical Insurance 7th Edition by Amy Blochowiak, Joanne Valerius, Nenna Bayes, Cynthia Newby
Edition 7ISBN: 978-1259683077 Exercise 23
Coding Hospital Services
Follow the inpatient coding guidelines for (1) identifying the principal diagnosis, (2) coding suspected conditions, and (3) differentiating between statements of admitting, principal, comorbidity, and complication diagnoses as you analyze these cases.
A. What is the principal diagnosis for this patient?
Discharge Date: 07/03/2018
Patient: Kellerman, Larry H.
Patient is a 59-year-old male who was recently found to have some evidence of induration of his prostate gland. He was referred for urologic evaluation and admitted to the hospital for further study and biopsy. Under general anesthesia, cystoscopy revealed early prostatic enlargement, and needle biopsy was accomplished. Pathological examination of the tissue removed confirmed the presence of adenocarcinoma of the prostate.
B. What is the admitting diagnosis for this patient?
Room: S-920
Patient: Koren, Sarah I.
Admission Date: 10/09/2018
Chief Complaint: Severe, right upper abdominal pain radiating to the back.
History of Present Illness: This 38-year-old female reports having this severe pain for two weeks. She has had some nausea and vomiting. Condition worsened by previous treatment with pain medication and Tagamet. Previous ultrasound of her gallbladder showed a very thickened gallbladder wall with a large stone, impacted at the neck of the cystic duct. Her family physician has admitted her to be taken to surgery for a cholecystectomy. She notes diarrhea a few days ago but no other change in bowel habits.
Impression: Probable acute cholecystitis.
C. Identify the principal diagnosis, the principal procedure, the comorbidity diagnosis, and the complication in the following discharge statement.
Flora Raniculli is a 65-year-old female admitted to the hospital with a three-month history of cough, yellow-sputum production, weight loss, and shortness of breath. Chest X-ray reveals probable bronchiectasis. Patient may also have pulmonary fibrosis. She underwent a bronchoscopy that showed thick secretions in both lower lobes. Postbronchoscopy fever finally cleared up. She is now being discharged and will call me in one week for a progress report.
Follow the inpatient coding guidelines for (1) identifying the principal diagnosis, (2) coding suspected conditions, and (3) differentiating between statements of admitting, principal, comorbidity, and complication diagnoses as you analyze these cases.
A. What is the principal diagnosis for this patient?
Discharge Date: 07/03/2018
Patient: Kellerman, Larry H.
Patient is a 59-year-old male who was recently found to have some evidence of induration of his prostate gland. He was referred for urologic evaluation and admitted to the hospital for further study and biopsy. Under general anesthesia, cystoscopy revealed early prostatic enlargement, and needle biopsy was accomplished. Pathological examination of the tissue removed confirmed the presence of adenocarcinoma of the prostate.
B. What is the admitting diagnosis for this patient?
Room: S-920
Patient: Koren, Sarah I.
Admission Date: 10/09/2018
Chief Complaint: Severe, right upper abdominal pain radiating to the back.
History of Present Illness: This 38-year-old female reports having this severe pain for two weeks. She has had some nausea and vomiting. Condition worsened by previous treatment with pain medication and Tagamet. Previous ultrasound of her gallbladder showed a very thickened gallbladder wall with a large stone, impacted at the neck of the cystic duct. Her family physician has admitted her to be taken to surgery for a cholecystectomy. She notes diarrhea a few days ago but no other change in bowel habits.
Impression: Probable acute cholecystitis.
C. Identify the principal diagnosis, the principal procedure, the comorbidity diagnosis, and the complication in the following discharge statement.
Flora Raniculli is a 65-year-old female admitted to the hospital with a three-month history of cough, yellow-sputum production, weight loss, and shortness of breath. Chest X-ray reveals probable bronchiectasis. Patient may also have pulmonary fibrosis. She underwent a bronchoscopy that showed thick secretions in both lower lobes. Postbronchoscopy fever finally cleared up. She is now being discharged and will call me in one week for a progress report.
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Medical Insurance 7th Edition by Amy Blochowiak, Joanne Valerius, Nenna Bayes, Cynthia Newby
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