Case Scenario: 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.
Principal Diagnosis and Explanation
|
Principal Diagnosis:
|
Pneumonia
|
|
|
|
Explanation:
|
|
Principal Diagnosis:
|
Septicemia
|
|
|
|
Explanation:
|
|
Principal Diagnosis:
|
Respiratory failure
|
|
|
|
Explanation:
|
|
Principal Diagnosis:
|
Congestive heart failure
|
|
|
|
Explanation:
|
|
Principal Diagnosis:
|
Cholecystectomy with cholelithiasis
|
|
|
|
Explanation:
|
|
Principal Diagnosis:
|
Preeclampsia
|
|
|
|
Explanation:
|
|
Principal Diagnosis:
|
Thrombophlebitis
|
|
|
|
Explanation:
|
|
Principal Diagnosis:
|
Cerebrovascular accident (CVA)
|
|
|
|
Explanation:
|
What would you tell Javier about each?
Attachment:- Documentation Support for Principal Diagnosis.rar