Read and identify the “why” and the “what” in the following scenario: This is a 65 year old female who presents due to ongoing problem with cough, fever, and cold symptoms. Chest x-ray and CBC are ordered, which indicate the presence of an upper respiratory infection. Patient also complains of urinary frequency, therefore, a urinalysis is performed that confirms the diagnosis of urinary tract infection.

Identify the: Why (Diagnosis/condition(s) and the What(Procedure(s)?

Diagnoses: Upper respiratory infection; urinary frequency; cough, fever, and cold symptoms, urinary tract infection. Procedure/services: Chest x-ray, urinalysis and CBC

Read and identify the “why” and the “what” in the following scenario: This 45 year old patient came to the physician for evaluation of her borderline hypercholesterolemia for which she takes niacin in doses of 1500 mg daily. Her cholesterol initially was 345, and it has now dropped to 252. She has a history of hypoglycemia, which has improved with diet and supplements. She also has an approximately 6 month history of insomnia. Allergy to codeine. Has had some bloating after meals and extremely cold extremities for which she wears gloves in the house during the winter months. Family history – mother with valvular heart disease, father with heart attack.

Identify the: Why (Diagnosis/condition(s) and What (Procedure(s)?

Diagnoses: Borderline hypercholesterolemia, hypoglycemia, insomnia ProcedureL Evaluation and Management

Read and identify the “why” and the “what” in the following scenario: This 58 year old female noted a sensation of shortness of breath in the high substernal region of her chest. She also describes a feeling of heaviness or pressure. I believe that this sensation is more consistent with angina than true air hunger. This sensation reportedly lasted about 20 minutes. There was no radiation with discomfort and no associated symptoms. An evaluation and x-ray were performed.

Identify the: Why (Diagnosis/condition(s) and the What (Procedure(s)?

Diagnoses: Shortness of breath, chest heaviness or pressure, angina Procedures/Services: An evaluation and x-ray

The various medical record formats include what:

 Problem-oriented MR, Source-oriented MR, Integrated MR

Explain the difference between technical component and professional component coding and billing.

The technical component is coding and billing for the hospital portion of a service and inpatient admission. Professional component is the coding and billing of professional service a physician provide to the patient while the patient was an inpatient or had outpatient services.

Explain what the term SOAP means and identify which medical record format it pertains to.

Soaping is a method of writing progress notes with the problem oriented medical record. Subjective (data), Objective (data), Assessment (of diagnosis) and Plan (of care).

What is a physician query form and what is it used for?

The physician query form is a commmunication tool used by coders to providers to make inquries regarding documentation that is not clear or incomplete.