A 28-year-old male with a history of IV heroin dependence is admitted for pneumonia. A pulmonologist
is consulted to assist with the patient's treatment and an antibiotic for Pneumocystis carinii pneumonia
is administered. Low potassium is treated as well. The final diagnoses were coded as: B20, B59, E87.6,
and F11.21. What is the discrepancy noted between the coding and the documentation?
A. The "history of" code reflects abuse rather than dependence
B. The correct code for the pneumonia should be J18.9
C. The assignment of B20 has no supportive documentation
D. The hypokalemia should not be coded as that is integral to the pneumonia - answer✔C. The
assignment of B20 has no supportive documentation.
The diagnosis of HIV (B20) has no supporting diagnosis documented. In this case a query would be
appropriate to determine if the patient has HIV since he is a previous IV drug user and the type of
pneumonia is often seen in patients with an HIV diagnosis (Schraffenberger and Palkie 2022, 127-131).
A patient was admitted with pneumonia. A sputum culture was able to identify Mycoplasma
pneumoniae, which the consulting pulmonologist documented as the cause of the pneumonia. The
patient was also diagnosed with an E. coli UTI. In the final diagnosis statement, the attending physician
documents E. coli pneumonia and UTI. How will the coding professional code the pneumonia?
Assign the code based on the final diagnostic statement.
Assign the pneumonia code based on the consultant's documentation.
Assign the pneumonia code based on the sputum result.
Query the attending provider to clarify the pneumonia organism. - answer✔Query the attending
provider to clarify the pneumonia organism.
An operative report indicates the physician performed metatarsal surgery but all other information in
the health record points to need for metacarpal surgery. What step should the coding professional take
upon this discovery?
A. Code the metatarsal surgery as that is what is documented in the operative report.
B. Code the metacarpal surgery since the op report was clearly an error.
C. Query the physician to determine which body area the surgery involved.
D. Suspend the chart and contact the coding supervisor as to which procedure to code. - answer✔C.
Query the physician to determine which body area the surgery involved.
When there is conflicting information in the patient record, the coding professional should query the
physician for clarification (AHIMA 2022).
A 78-year-old patient is admitted with shortness of breath and a chest x-ray reveals infiltrates in the lung
with pleural effusion. The patient also has a history of hypertension with left ventricular hypertrophy.
The patient is given Lasix and the shortness of breath is relieved. From the information given, what is
the probable principal diagnosis?
A. Pneumonia
B. Congestive heart failure
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