HI 253 Purdue University Otitis Media Medical Record Analysis ASSIGNMENT DETAILS Your coding manager asks you to review the above case (#ED322223) for any

HI 253 Purdue University Otitis Media Medical Record Analysis ASSIGNMENT DETAILS

Your coding manager asks you to review the above case (#ED322223) for any coding discrepancies. You notice that additional information from the provider would allow you to code the diagnosis to a higher level of specificity. Your manager requests that you generate a physician query to resolve the issue.
Describe the deficiency that was present in the health record that would require a physician query to resolve. Record your response in the box below.
Refer to the Unit 5 Supplemental Readings “Guidelines for achieving a compliant query practice” and compose a written query to the physician to clarify the deficiency in the health record. Create and record your completed query in the box below.
Submit the completed assignment worksheet to the Unit 5 Assignment Dropbox.

Requirements: I have attached the full assignment instructions

Your assignment should have no more than 10% quoting.Please use paraphrasing, in-text citation, and a list of references, as appropriate.

Your assignment should:

Have a cohesive viewpoint that is clearly established and sustained.
Follow the conventions of Standard English (correct grammar, punctuation, and spelling).
Be well ordered, logical and unified, as well as original and insightful.
Follow APA citation style as needed (Please note:You may access information regarding appropriate citation information at the Purdue Global Writing Center).
The word count should be 75-100 words. HI253 Medical Coding I
Unit 5 Assignment Worksheet
Unit outcomes addressed in this Assignment:
? Analyze a medical record for errors or
omissions that require the creation of a
physician query.
?
Develop appropriate physician queries to
resolve data and coding discrepancies.
Course outcome addressed in this Assignment:
HI253-2.1: Recognize the information documented
within a health record that leads to quality coding
practices.
AHIMA’s Professional Coding Approved
Program (PCAP) Mapping:
Domain I. Data Content, Structure & Standards
(Information Governance)
Subdomain I.B. Health Record Content and
Documentation
• 1. Analyze the documentation in the health
record to ensure it supports the diagnosis
and reflects the patient’s progress, clinical
findings, and discharge status (Bloom’s
Level 4)
o Content of health record
o
Documentation requirements of the
health record
o Health information media
? Paper, computer, webbased document imaging
• 2. Verify the documentation in the health
record is timely, complete, and accurate
(Bloom’s Level 4)
o Documentation requirements of the
health record for all record types
? Acute, outpatient, LTC,
rehab, behavioral health
Subdomain V.D. Clinical Documentation
Improvement
• 1. Identify discrepancies between
supporting documentation and coded data
(Bloom’s Level 3)
o Clinical outcomes measures and
monitoring
• 2. Develop appropriate physician queries to
resolve data and coding discrepancies
(Bloom’s Level 6)
o AHIMA CDI toolbox
o Professional communication skills
==================================================================
CASE #ED322223
ED/ PROVIDER NOTE
PCP: Medical Center
Date of Arrival: 4/12/2014
Diagnosis: L AOM. Patient is very well-appearing and well-hydrated with no evidence of
meningitis,
mastoiditis, pneumonia, or other SBI.
Disposition and Plan of Care:
-Discharge home
-Amoxicillin 620 mg PO BID x 10 days
-Follow-up and return precautions as per ACI
History of Present Illness: Source: Mother and
No ongoing medical conditions
sister
Family History:
CC: RN, congestion, and ear pain
Negative for chronic childhood conditions
History of Present Illness: is a previously healthy Social History:
23 month old with tactile fever x 2 days with
Lives with parents and siblings
ear pain since 0300 this morning. +RN and
Medications:
congestion for the past two days. Taking less PO
Allergies: No Known Allergies
than usual,
Immunizations Status: up to date
but urinating normally. No vomiting or diarrhea. No
ROS:
other concerns.
Constitutional: fever
Past Medical History:
HEENT: RN, congestion, ear pain
No prior hospitalizations
Respiratory: negative
No prior surgeries
Cardiovascular: negative
04/15/2020
Unit 5 Assignment worksheet
1
HI253 Medical Coding I
ROS (cont’d):
Gastrointestinal: negative
Genitourinary: negative
Musculoskeletal: negative
Hematology/Lymphatic: negative
Skin: negative
Central Nervous: negative
PE:
Pulse 158 [crying] | Temp 98.2 | Resp 30 | Wt 15.3
kg, is alert, well developed, well nourished, in no
acute distress
HEAD: normocephalic and atraumatic
EYES: pupils equal, round and reactive to light and
extra-ocular movements intact
EARS: R TM is normal appearing. L TM bulging
and erythematous with purulent effusion
NOSE: no discharge
OROPHARYNX: mucous membranes moist with no
oral lesions
NECK: neck is supple with full active range of
motion and no adenopathy
CHEST: clear to auscultation bilaterally and no
wheezes, rales, or rhonchi
CARDIAC: regular rhythm, no murmurs and normal
S1 and S2, no gallop
ABDOMEN: nondistended, soft, nontender to
palpation , no hepatosplenomegaly, no masses, no
guarding
or rebound tenderness and normoactive bowel
sounds
BACK: exam deferred
GU: exam deferred
EXTREMITIES: brisk capillary refill and no edema
SKIN: no rashes and no petechiae
ASSIGNMENT DETAILS
1.
Your coding manager asks you to review the above case (#ED322223) for
any coding discrepancies. You notice that additional information from the provider
would allow you to code the diagnosis to a higher level of specificity. Your manager
requests that you generate a physician query to resolve the issue.
2.
Describe the deficiency that was present in the health record that would
require a physician query to resolve. Record your response in the box below.
3.
Refer to the Unit 5 Supplemental Readings “Guidelines for achieving a
compliant query practice” and compose a written query to the physician to clarify
the deficiency in the health record. Create and record your completed query in the
box below.
4.
Submit the completed assignment worksheet to the Unit 5 Assignment
Dropbox.
Requirements:
Your assignment should have no more than 10% quoting. Please use paraphrasing, in-text
citation, and a list of references, as appropriate.
Your assignment should:
• Have a cohesive viewpoint that is clearly established and sustained.
• Follow the conventions of Standard English (correct grammar, punctuation, and spelling).
• Be well ordered, logical and unified, as well as original and insightful.
• Follow APA citation style as needed (Please note: You may access information
regarding appropriate citation information at the Purdue Global Writing Center).
• The word count should be 75-100 words.
04/15/2020
Unit 5 Assignment worksheet
2
HI253 Medical Coding I
Unit 5 Assignment Chart Review & Physician Query
Chart reviewed: #ED322223
1. Describe the deficiency that was present in the health record and would require a
physician query to resolve:
2. Compose a query to the physician to resolve the deficiency:
Submitting your work:
After completing this assignment worksheet, save it to your computer as a Word DOC
and then upload it to the Unit 5 Assignment dropbox.
Unit 5 Assignment Grading Rubric:
Assignment Requirements
Part 1: Student has demonstrated the ability
to identify deficiencies within the health
record.
Part 2: Student has demonstrated
professional communication through the
composition of a physician query.
04/15/2020
Unit 5 Assignment worksheet
Points
possible
Points
earned
0–10
0–10
2
HI253 Medical Coding I
Total (Sum of all points)
Points deducted for spelling, grammar,
and/or APA errors (Max 10%)
Adjusted total points
Instructor Feedback:
04/15/2020
Unit 5 Assignment worksheet
3

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