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. D
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.
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