Inpatient Coding Audit Test 50 pts Possible Directions: For the Cases provided identify coding errors present or cases that were coded correctly. Provided the correct codes and reasons codes assigned were incorrect. Case 1 Inpatient Admission: The patient fell at his single-family home and was unable to get up. Neighbors found him several hours later, and he does not remember any circumstances surrounding the event. Blood sugars were monitored, and a diagnosis of diabetes mellitus was given. It became rapidly evident to the attending physician that, even with dietary restriction, the patient would need insulin therapy to lower his blood sugar level. Insulin therapy was started. The only other positive finding was beta-Streptococcus group B, which grew from urine culture and was treated with oral antibiotics. Discharge Diagnosis: New onset type 2 diabetes mellitus, out of control Urinary tract infection with beta-Streptococcus Coder A coded: E11.60 N39.0 P39.3 Y92.099 An Audit of the codes submitted indicated the following incorrect, missing, wrong principal DX, or codes that should not be present. Auditor Remarks: Case 2 Inpatient admission: The patient was diagnosed with Coombs’ negative hemolytic anemia four years earlier. Since diagnosis, her disease course waxed and waned. During some bouts, she had 15 to 20 blood transfusions of two to three units of packed red blood cells each. This admission was for splenectomy. The plan also called for removing a kidney stone on her left side, which was identified on her preadmission workup. Both surgeries, total splenectomy and laparoscopic pyelolithotomy, were performed without incident. Her postoperative recovery also went smoothly. Discharge Diagnosis: Hypersplenism secondary to acquired hemolytic anemia Stone, left kidney Coder A coded: D73.1 N20.3 07TP0ZZ An Audit of the codes submitted indicated the following incorrect, missing, or codes that should not be present. Auditor Remarks