On admission, bilateral lower extremity edema is noted, however, there are no other clinical indicators to support malnutrition.
After reviewing the scenario, answer the questions below using the skills you learned in this lecture as well as your references regarding the latest coding changes and physician queries.
Review the following queries and determine whether or not the query is compliant. Why or why not? Defend your reasoning.
Clinical Scenario 1: On admission, bilateral lower extremity edema is noted, however, there are no other clinical indicators to support malnutrition.
Query 1: Do you agree that the patient’s bilateral lower extremity edema is diagnostic of malnutrition? Once you’ve reached a conclusion, please explain your answer.
Clinical Scenario 2: In the ED, a foley catheter was inserted for the patient with dysuria and elevated WBCs that was removed two days after admission. The cultures were positive for E.coli and the progress note reflect a catheter associated urinary tract infection (CAUTI) and this was coded. Quality has requested review of the HAC condition to ensure it should be coded as it does not meet the CDC definition for CAUTI.
Query 2: The quality department has indicated that your documented diagnosis of CAUTI does not meet the CDC definition which impacts the Hospital Acquired condition statistics for your profile as well as the hospital. Does your patient have a catheter associated urinary tract infection? Once you’ve reached a conclusion, please explain your answer.
Clinical Scenario 3: A patient is admitted with cellulitis around a recent operative wound site, and only cellulitis is documented without any relationship to the recent surgical procedure.
Query 3: Is the cellulitis due to or the result of the surgical procedure. Once you’ve reached a conclusion, please explain your answer.
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