Assignment task:
A 79 year old nursing home patient, Mary Creed was admitted to Parkview hospital with severe cellulitis of the left lower leg. The cultures grew streptococcus B, and this was documented by the physician as the cause of the cellulitis. The patient was given IV antibiotics. She also has dominant right-sided hemiplegia from an old CVA and a neurologist was brought in for a consult. During her inpatient stay, she also was found to have a stage 4 decubitus ulcer in the left buttock region.
Coder I assigned:
L03.119, L89.324, I69.353
POA indicators; L03.119 - N, L89.324 - Y, I69.353 - N
As the coding supervisor, review the clinical documentation, the diagnosis codes & the
POA indicators assigned by this coder.
Answer these 4 questions for Health Record #2:
1) What coding quality issues do you find as you are auditing the coder's work?
2) What would be your feedback to this coder?
3) Are any diagnosis code(s) missing? If so, what are the diagnoses that should be added to this case? What should the correct diagnoses be for this case?
4) Are the POA indicators correct?