Pleаse review the inpаtient scenаriо: Pre-оperative Diagnоsis: Left progressive acoustic neuroma Post-operative diagnosis: Left progressive acoustic neuroma Procedure performed: Gamma-knife resection of the neuroma Indications: This 46-year-old, male, patient with chronic benign HTN and rheumatoid arthritis presented a month ago with new onset symptoms of hearing loss on the left side, tinnitus, and headache. MRI shoed an enhancing mass in the left cerebellopontine (CP) angle cistern and left internal auditory canal. Due to the complexity of the mass location, the patient opted to have gamma knife surgery. Diagnostic codes: D33.3 - Benign neoplasm of cranial nerves I10 - Essential (primary) hypertension M06.9 - Rheumatoid arthritis, unspecified H91.92 - Unspecified hearing loss, left ear H93.19 - Tinnitus, unspecified R51.9 - Headache, unspecified H93.8X2 - Other specified disorders of left ear 1. Are all of the codes listed correct (yes or no)? [1] Question 1 will require you to step into the auditor position. Review the case and each code provided for accuracy and completeness. Do not evaluate for sequence errors at this time. Consider: Are there too many diagnoses? Are they coded accurately? Are all the codes applicable? Are signs and symptoms included in the codes? If any of the codes are inaccurately or inappropriately coded, such as codes that are an integral part of the confirmed condition, the answer should be no. 2. Are all of the diagnosis code(s) in the correct sequence (yes or no)? [2] Question 2 will require you to evaluate the sequence provided and audit the coders work to determine if the codes are reported in the correct order. Do not provide any correction at this time. If the appropriately coded diagnoses from Question 1 are out of sequence, answer “No.” Ignore any codes that are irrelevant to the case. 3. If the listed code(s) and or sequence of the code(s) is incorrect you must list the corrected code(s) sequence or state "no changes. [3] (Answer format: X11.11, Y11.11, Z11.11) In Question 3, If you found any inaccuracies that require changes, list the corrected code(s) and the proper sequence that accurately reflect the encounter as it has been documented. If you determined that the codes were all correct and the sequence is correct, the answer should be "no changes". If you determined that the codes were all correct and the sequence is correct, the answer should be "no changes".
Pleаse review the inpаtient scenаriо: Preоperative diagnоsis: Nonhealing diabetic right foot ulcer Postoperative diagnosis: Nonhealing diabetic right foot ulcer Procedure performed: Below the knee amputation Indications: The patient is a 68-year-old male with a long-standing history of DM I. He has non-healing ulcers of bilateral feet and has been seeing wound care for many years. The patient failed conservation attempts and was admitted for amputation of only the right foot for worsening diabetic foot ulcer with bone necrosis. Diagnostic codes: L97.514 - non-pressure chronic ulcer of other part of right foot with necrosis of bone. E10.9 - Type I diabetes mellitus without complication 1. Are all of the codes listed correct (yes or no)? [1] Question 1 (Q1) will require you to step into the auditor position. Review the case and each code provided for accuracy and completeness. Do not evaluate for sequence errors at this time. Consider: Are there too many diagnoses? Are they coded accurately? Are all of the codes applicable? If any of the codes are inaccurately or inappropriately coded, such as codes that are an integral part of the confirmed condition, the answer should be no. 2. Are all of the diagnosis code(s) in the correct sequence (yes or no)? [2] Question 2 (Q2) will require you to evaluate the sequence provided and audit the coders work to determine if the codes are reported in the correct order. Do not provide any correction at this time. If the appropriately coded diagnoses from Question 1 are out of sequence, answer “No.” Ignore any codes that are irrelevant to the case. 3. If the listed code(s) and or sequence of the code(s) is incorrect you must list the corrected code(s) and sequence or state "no changes. [3] (Answer format: X11.11, Y11.11, Z11.11) In Question 3, If you found any inaccuracies that require changes, list the corrected code(s) and the proper sequence that accurately reflect the encounter as it has been documented. If you determined that the code(s) were all correct and the sequence is correct, the answer should be "no changes". If you determined that the codes were all correct and the sequence is correct, the answer should be "no changes".