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?

A 75-year-old female was admitted for chest pain and underwent a diagnostic cardiac catheterization with access via the right radial artery. An acute myocardial infarction was averted by an insertion of two drug-eluting stents. Following the catheterization, the patient developed thrombophlebitis documented as due to the catheter in the right common femoral vein. When coding for the facility encounter, what information needs to be addressed?

Which of the following statements is true regarding the term workforce as it is referred to under HIPAA?

Choose the correct secondary diagnosis code(s) that apply.

Use the following table to answer questions 42 and 43.    Point of Origin Table

A fistulectomy is being performed on a patient with an anorectal fistula that has recurred six months after initial treatment. Is any information missing to assign an ICD-10-CM diagnosis code?