Coding Management and Compliance Unit 1 Assignment 1 Coding Guidelines Key Assessment LO#3

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CASE22-3.docx

CASE 2-3: Documentation Support for Principal Diagnosis

You are the coding supervisor at Vale Community General Hospital. An HIM student, Javier, is working with you today. He is looking at some charts and has asked you how you determine if the documentation supports the codes. You decide to walk through the charts with him and explain each one. The principal diagnoses are shown in  Table 2-3 .

Table 2-3: Principal Diagnosis and Explanation

            Principal Diagnosis and Explanation

Principal Diagnosis:

Explanation:

Pneumonia—J18.9

Principal Diagnosis:

Explanation:

Septicemia—A41.9

Principal Diagnosis:

Explanation:

Respiratory failure J96.00

Principal Diagnosis:

Explanation:

Congestive heart failure I50.9

Principal Diagnosis:

Explanation:

Cholecystectomy with cholelithiasis K80.00

Principal Diagnosis:

Explanation:

Preeclampsia – O15.2

Principal Diagnosis:

Explanation:

Thrombophlebitis I80.01

Principal Diagnosis:

Explanation:

Cerebrovascular accident (CVA)- I63.9

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· What would you tell Javier about each?