Emergency Department – Patient 7Use the chart documentation below for questions 119-121.___________________________________________________________________________________________________________________________History and Physical ExamDATE: 7/16CHIEF COMPLAINT: Shortness of breath and dyspneaHISTORY (PROBLEM FOCUSED):HISTORY OF PRESENT ILLNESS:This 81-year-old presents today with complaints of shortness of breath and dyspnea. No cough or sputum production. No pleuritic chest pain or hemoptysis. She has vague complaints of some pain. She has been taking acetaminophen without much relief. Patient is accompanied by her daughter.PAST MEDICAL HISTORY:       COPD    Chronic hypoxic respiratory failure    History of lung cancerFAMILY HISTORY: Reveals that her mother has a history of migraines and depression.SOCIAL HISTORY: She does not smoke or use alcohol.MEDICATION: Albuterol inhaler 180mcg (2 puffs) inhaled orally every 4–6 hours; not to exceed 12 inhalations/24 hours; oxygen 2 liters.ALLERGIES: NonePHYSICAL EXAMINATION (PROBLEM FOCUSED):MDM: LowVITAL SIGNS: Blood pressure 136/82, pulse 94, respiratory rate 18, weight 100.5 pounds, oxygen saturation 97% on two liters, continuousGENERAL: Chronically ill-appearing, thin, elderly, white femaleHEENT: Pupils are minimally reactive. Bilateral arcus senilis. Oral cavity is grossly normal.NECK: No lymphadenopathyLUNGS: Decreased breath sounds. Prolonged respiratory phase. Scattered rales are heard at the lung bases.HEART: Distant heart sounds. Regular rhythm.ABDOMEN: Soft. Liver and spleen not enlarged.EXTREMITIES: Trace edema. No cyanosis or clubbing.RADIOLOGY: Chest x-ray ordered and reviewed without benefit of the radiologist’s report. Heart size is at the upper limits of normal. There is scarring and retraction in the right lower lung field. There are emphysematous changes noted. Previous pulmonary function studies are reviewed. LABORATORY: CBC ordered and all values within normal limits.ASSESSMENT:1. COPD2. Pain, multifactorial3. History of lung cancerFOLLOW-UP: Hydrocodone every 6–8 hours for pain. Follow-up with primary care provider in two weeks. Maintain current O2 levels at 2 liters.

A coding supervisor has reviewed the codes assigned on an account and returned it for a correction to a procedure code. The coding professional who originally assigned the codes does not agree with the suggested revision and has Coding Clinic guidance that supports the original code assignment. However, the coding professional does not want a quarrel with the coding supervisor and makes the change anyway. Is this ethical?

After a two-week stay in the hospital, a patient was transferred to Oak Woods, a skilled nursing facility. There his condition deteriorated and he was transferred to hospice. The patient required an admission to the hospital for pain relief. The point of origin code entered for the second hospital admission was 5. Is this correct?

What is the case mix for the information provided? Table for 76(Note: The MS-DRG numbers and weights are not actual numbers and weights for fiscal year 2026.)

A nursing home patient has been admitted for complaints of urinary burning, fever, and chills for the past week. After study, the discharge diagnosis is Proteus mirabilis, urinary tract infection. Which of the following represents the correct diagnoses and appropriate sequencing of those conditions?

A diagnosis documented by the anesthesiologist in the preoperative evaluation that would affect MS-DRG assignment is missing from the patient’s discharge summary. The coding professional finds no evidence that the diagnosis contradicts documentation from the attending physician. What should the coding professional do?

A patient was admitted with redness and blurred vision in the left eye within one week of a cornea transplant. Due to the timing, the coding professional thought that it may represent a transplant rejection following cornea transplant. He sends a Corneal Transplant Rejection query to the attending provider listing the clinical indicators.Is this a compliant query?

A 27-year-old female presents to the emergency department complaining of shortness of breath and wheezing. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unrelieved following treatment. What diagnosis might the coding professional suspect?

Interventional Radiology – Patient 4Use the chart documentation below for questions 110-112.__________________________________________________________________________________________________________________________Interventional Radiology ReportEXAMINATION: Ultrasound guided liver biopsyHISTORY: Carcinoma of the lower lobe of the right lung, evaluation for hepatic metastasisPROCEDURE: The patient was placed in the supine position. After informed consent was obtained, the right upper quadrant was prepped and draped in a sterile fashion. Local anesthesia was administered using 1% lidocaine. Under real-time ultrasound guidance, a suitable lesion in the right hepatic lobe was identified. A 16-gauge core biopsy needle was advanced into the lesion using a coaxial technique. Two core samples were obtained and placed in formalin for histopathological analysis. Hemostasis was achieved, and the patient tolerated the procedure well without immediate complications. Post-procedure ultrasound confirmed no evidence of active bleeding or hematoma formation.IMPRESSION: Successful ultrasound-guided core biopsy of a right hepatic lesion in a patient with known carcinoma of the lower lobe of the right lung. No immediate complications.PATHOLOGY REPORT: Metastatic adenocarcinoma of the liver, consistent with primary lung origin.

Which of the following would meet the definition of “other diagnosis” as provided by the UHDDS?