Reference no: EM133729527

Question

Mr. Donald Black is a male patient seen in the emergency department with a chief complaint of severe fatigue. The patient has a past medical history of gastroesophageal reflux disease and renal insufficiency. After a short time in the ED, the patient complains of shortness of breath and chest pain. The patient is admitted for further workup and treatment. Diagnostic testing includes laboratory testing and an EKG, and the patient is determined to have congestive heart failure. On the second day of admission, a chest x-ray reveals an abnormality noted by the radiologist as pleural effusion. The patient is administered intravenous antibiotics and IV diuretics to treat the CHF and pleural effusion. Discharge diagnosis is CHF. The coder should: What is the correct answer? Question 1 options: Report the ICD-10-CM code for CHF only. Query the physician to ask whether GERD instead of CHF should be listed as final diagnoses. Query the physician to ask whether the patient has pneumonia, based on the radiology report and the antibiotic treatment. Query the physician to ask whether the shortness of breath and chest pain should be listed as final diagnoses.