Inpatient Queries Coding Practice Test PDF

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Inpatient Doctor Queries Practice Test...

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NAME: DATE:

INPATIENT QUERIES CODING ASSESSMENT

1. This patient was admitted with gastrointestinal bleed, epigastric pain, and dizziness for the past eight hours. Patient has history of Chronic Obstructive Pulmonary Disease. The physician performed a colonoscopy which revealed duodenal ulcer with bleeding. Vital Signs: Pulse at 170, Blood Pressure of 90/75, Hemoglobin and Hematocrit were 23 and 21 respectively. Progress Note stated the patient is also hypotensive with a drop in the patient’s Hemoglobin and Hematocrit. The Physician ordered two units packed blood cells to be transfused. The patient was discharged on Pepcid and Iron tablets. Discharge Summary Final Diagnosis revealed: Duodenal ulcer and anemia. Which query form, if any, should be used? A. COPD Query Form B. Specificity Query Form C. Anemia Query Form D. Hypotension Query Form

2. This 93 year old patient from a nursing home was admitted to Hospital. The H&P revealed a chief complaint of shortness of breath, weakness, ineffective cough, aspiration and fever. Sputum culture were drawn and returned negative, however chest X-ray did reveal right lower infiltrates. The physician orders and the medication record stated the patient was treated with IV Levaquin. During the course of hospitalization, nausea and vomiting was also reported. A swallow study was obtained and revealed aspiration. The final Progress Note listed Pneumonia as the final diagnosis. Which query form, if any, should be used? A. Aspiration Pneumonia Query Form B. No Query Form Needed C. Pneumonia Query Form D. General Physician Query Form

3. A 64 year old male presented to the ED with chest pan. H&P revealed that the patient has no past history of chest pain and is admitted for further work up. Impression is chest pain, R/O CAD. The patient underwent Cardiac Cath and the results were negative for CAD. Gastrointestinal consult was ordered by physician. GI doctor states that patient’s chest pain is probably secondary to GERD. Patient is discharged the next day with GI meds. Discharge summary diagnosis documented by the attending physician was chest pain of unknown etiology. Which query form, if any, should be used? A. Diagnosis Occasioning the Admission Query Form B. General Physician Query Form C. No Query Form Needed D. Present on Admission Form

4. A 64 year old male was brought to the Emergency Department because of progressive shortness of breath eventual respiratory distress with hypoxia and cough. His oxygen saturation was decreasing below 90%. The patient was started on Bi-PAP and IV Antibiotics and admitted to the hospital. ED record diagnosis was Respiratory distress with hypoxia and pneumonitis. Vital signs showed oxygen saturation 83. Patients ABG Levels on admission were Pa02 of 52 and pH of 7.21. Physicians’ initial impression was: 1. Acute Respiratory Distress 2. Pneumonitis. Progress Note Day 3: documents acute respiratory failure, multifactorial. Pulmonary consultation stated hypoxemic respiratory failure secondary to pneumonitis and pulmonary fibrosis. Discharge Summary documents Acute Respiratory Failure and Pneumonia. Which query form, if any, should be used? A. Aspiration Pneumonia B. Diagnosis Occasioning the Admission Query Form C. General Physician Query Form D. No Query Form Needed

5. A 79 year old nursing home patient was admitted with shortness of breath and increased temperature. The admission chest X-ray revealed bilateral infiltrates. IV antibiotics were initiated at time of admission. The physician ordered sputum cultures. The progress Note and sputum cultures showed the cultures positive findings E. Coli. Final Diagnosis on Discharge Summary is E. Coli Pneumonia. Which query form, if any, should be used? A. Urosepsis Query Form B. Infection Organism Query Form C. No Query Form Needed D. Pneumonia Query Form

6. An 85 year old male presented with complaints of acute mental status changes, lethargy and hypotension one day. The patient’s temperature was 103 degrees. Labs drawn on admission revealed increased White Blood Count at 60.4. Blood cultures and Urinalysis were positive for greater than 100.000 E. Coli. EKG reflected sinus tachycardia. The physician documented in the Progress Note Urosepsis, Bacteremia, Diabetes Mellitus and Hypertension. The patient was treated with IV Levaquin and Recephin. The Physician documented on Discharge Summary diagnoses: Urosepsis, Diabetes Type II, Hypertension, and Bacteremia. Which query form, if any, should be used? A. Urosepsis Query Form B. Infection Organism Query Form C. Specificity Query Form D. No Query Needed

7. A 70 year old patient comes into the ED from home with fever. Patient is found to have a severe UTI. ED documentation reports severe weight loss. The patient is also noted to have cold hands and feet with a weak pulse. Skin appears to be dry and scaly. H&P: states that the patient is admitted to the ED from home with severe UTI. Patient appears to be able to care for herself at home. The patient’s daughter reports that the patient has had significant weight loss over the last few weeks. Patient has noticeable pressure sores on legs and buttocks area and skin appears to be dry and scaly. Patient has history of hypertension and CHF. The patient is started on IV antibiotics for UTI. Lab Values report: low serum proteins and low potassium. Progress Note stated the patient has poor appetite with severe weight loss and a nutritional consult is ordered. The patient was discharged on Antibiotics. Discharge Summary Final Diagnosis: UTI, and Hypertension. Which query form, if any should be used? A. No Query Form Needed B. Malnutrition Query Form C. CHF Query Form D. Infection Organism Query Form

8. A 75 year old female nursing home patient on oral antibiotics for treatment of pneumonia was re-admitted with a chief complaint of shortness of breath, worsening cough, and fever of 101.2. Admit chest x-ray revealed patchy infiltrates, and sputum culture ordered grew out a Gram Negative organism. The attending physician treated the patient with IV Levaquin and P.O. antibiotics were continued upon discharge. The attending physician documented pneumonia as the final diagnosis. Which query form, if any, should be used? A. Infection Organism Query Form B. Aspiration Pneumonia Query Form C. No Query Form Needed D. Specificity Query Form

9. A 75 year old female nursing home patient admitted with Acute Exacerbation of COPD. Patient has a history of COPD and hypertension. Labs on admission reveal low platelets and low sodium levels. Progress Notes Day 2: documents COPD and low Platelets. Progress Note Day 3: documents Mild Thrombocytopenia. Final Diagnosis: The attending physician documented Acute Exacerbation of COPD and Mild Thrombocytopenia. Which query form, if any, should be used? A. COPD Query Form B. Specificity Query Form C. Diagnosis Occasioning the Admission Query Form D. No Query Form Needed

10. A 60 year old female is admitted to the hospital with abdominal pain, blood in stool, bloating after eating and diarrhea. Patient has a history of CHF and Crohn’s Disease and is presently on Lasix for CHF. Patient is diagnosed with Acute Exacerbation of Crohn’s Disease and is admitted to the hospital for IV antibiotics and corticosteroids. Progress Note on Day 2 states increased shortness of breath and swelling of the ankles. Echocardiogram revealed >50% Ejection Fraction and Left Ventricular Hypertrophy. Progress Note on Day 3 documents CHF. IV Lasix was initiated on the second day of the hospital stay for two days. Discharge Summary final diagnosis: Acute Exacerbation of Crohn’s Disease and CHF. A. No Query Needed B. Heart Failure Query Form C. General Query Form D. Specificity Query Form

11. A 65 year old male is admitted to the hospital with sepsis and a stage three pressure ulcer of the buttocks. The patient presented with increased fever of 103 accompanied with hypotension, increased white cell count and confusion. The patient was placed on IV Rocephin and the blood culture was negative. A consultation was obtained for the pressure ulcer and debridement was performed in the OR. The progress notes indicated the pressure ulcer was deep and the patient was discharged after four days with final diagnosis sepsis and stage three pressure ulcer of buttocks. The pathology findings include fascia. The operative report indicates the wound was debrided. A. Ulcer Stage Query Form B. Infection Organism Query Form C. Inpatient Debridement Query Form D. No Query Form Needed...