A 30-year-old male was admitted with severe nausea and abdominal pain. The patient has a history of Crohn’s Disease.

Scenario Dr. Yates: Query and Provider Response

Patient Documentation: A 30-year-old male was admitted with severe nausea and abdominal pain. The patient has a history of Crohn’s Disease. Since the patient is severely dehydrated, he is treated with IV fluids. Dr. Yates records diagnosis as dehydration.

 

HIM Question: I note that the abdominal x-ray shows severe inflammation of the sigmoid colon, and the patient has history of Crohn’s disease. If there is a causal relationship to the Crohn’s, please add documentation, and return to me.

 

Provider Response: Dr Yates documents the following in the patient’s record and returns the record to coding “The abdominal pain and nausea were likely caused by the patient’s Crohn’s disease.”

 

Scenario Dr. Yates: Identify two answers below, one from each column.

 

 

 

What does the Query seek to answer?

 

The Healthcare provider response is?

 

Answer Choices: Type of Question

 

Answer Choices: Healthcare Provider Response

 

POA-The query seeks to resolve the question of POA.

 

Secondary -The query seeks to clarify the presence of a secondary diagnosis.

 

Principal – The query seeks to clarify the principal diagnosis.

 

Not Necessary -The query was not necessary and should not have been sent to provider.

 

Unresolved -The provider response does not answer the query – the question is unresolved.

 

Complete-The provider response is complete, allowable, and helpful.

 

Not Allowed -The provider response is present but contains content that is not allowed.

 

Second Query -There is no provider response. A second query is necessary.

 

Which one below is the answer? I need to pick one below to select the answer.

 

 

 

Query= Not Necessary

 

Provider=Second Query

 

 

 

 

 

 

 

 

 

Query= Not Necessary

 

Provider= Not Allowed

 

 

 

 

 

 

 

 

 

Query= Not Necessary

 

Provider= Complete

 

 

 

 

 

 

 

 

 

Query= Not Necessary

 

Provider= Unresolved

 

 

 

 

 

 

 

 

 

Query= Principal

 

Provider=Second Query

 

 

 

 

 

 

 

 

 

Query = Principal

 

Provider= Not Allowed

 

 

 

 

 

 

 

 

 

Query= Principal

 

Provider= Complete

 

 

 

 

 

 

 

 

 

Query =Principal

 

Provider = Unresolved

 

 

 

 

 

 

 

 

 

Query =Secondary

 

Provider=Second Query

 

 

 

 

 

 

 

 

 

Query = Secondary

 

Provider=Not Allowed

 

 

 

 

 

 

 

 

 

Query =Secondary

 

Provider = Complete

 

 

 

 

 

 

 

 

 

Query = Secondary

 

Provider = Unresolved

 

 

 

 

 

 

 

 

 

Query = POA

 

Provider = Second Query

 

 

 

 

 

 

 

 

 

Query = POA

 

Provider = Not Allowed

 

 

 

 

 

 

 

 

 

Query = POA

 

Provider = Complete

 

 

 

 

 

 

 

 

 

Query = POA

 

Provider = Unresolved