AStrickland_POAassignment_041424

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Rasmussen College *

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HIM1103 SE

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Nursing

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Apr 29, 2024

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docx

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2

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Module 02 Assignment - UHDDS: PDX and POA Indicators Background : Review the ICD-10-CM Official Coding Guidelines, Sections II and III for definitions, and Appendix I. Present on Admission Reporting Guidelines (ICD-10-CM Code Book). Use the Present on Admission Indicators provided in the table below. Present on Admission (POA) Indicator Reporting Options/Definitions: Y – Yes Present at the time of inpatient admission N – No Not present at the time of inpatient admission U – Unknown Documentation is insufficient to determine if the condition is present on admission Instructions: Read each scenario and answer the associated questions by applying the coding guidelines and the POA indicators referenced above. Be sure to write your answer beneath each question, using complete sentences, reflecting proper spelling and grammar. All scenarios are inpatient admissions/discharges from a general acute-care hospital. Scenario 1 A patient presented to the Emergency Room with abdominal pain and bloody diarrhea. Past Medical History indicates a cholecystectomy had been performed one year ago. The patient also has a history of chronic Congestive Heart Failure. At discharge, the provider stated the following diagnoses: Status post cholecystectomy Congestive heart failure Acute diverticulitis Questions: 1. Which diagnosis should not be coded? The diagnosis that should not be coded is post cholecystectomy. 2. Which diagnosis is most likely the principal diagnosis? The diagnosis that is most likely the principal diagnosis is acute diverticulitis. 3. Which diagnosis is a comorbid condition? Congestive heart failure is a comorbid condition. 4. Which POA indicator would be applied to the acute diverticulitis? The POA would be Y. 5. Which POA indicator would be applied to the chronic congestive heart failure? The POA would be Y. Page 1 of 2
Scenario 2 The patient was admitted to the hospital with fever, cough and shortness of breath. It was noted that the patient has Type II Diabetes on Insulin. After study, the physician could not determine the exact cause of the presenting symptoms. The patient was treated with antibiotics, fluids and received one breathing treatment. During the hospitalization, the patient experienced a nosebleed and a headache. The final diagnosis was stated as “Possible viral pneumonia”. Questions: 1. What is the principal diagnosis? The principal diagnosis would be “possible viral pneumonia”. 2. Should the coder code the fever, cough and shortness of breath? Yes, these should be coded as they are the symptoms. 3. Which POA indicator would be assigned to a diagnosis of “nosebleed”? The POA would be N. 4. Which coding guideline under Section II. Selection of Principal Diagnosis would be applied? Specify the Letter Value and the Corresponding Guideline (bold print header only). H. Uncertain diagnosis. 5. Should the Type II Diabetes be coded? No this should not be coded as it is a previous diagnosis. 6. Which POA indicator would be assigned to a diagnosis of “headache”? The POA would be N. Page 2 of 2
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