Scenario 1: Clinical Documentation: The patient presented to the Emergency

Scenario 1: Clinical Documentation: The patient presented to the Emergency Room due to lacerations of left hand. The laceration on the left index finger was 2 cm in length. The second laceration was of the palm of the hand and measured 3.5 cm. Both lacerations repaired were superficial in nature. Type of Documentation Diagnosis(es) Procedure(s) Coding Classification System(s) Coding Guideline(s) and/or Conventions Scenario 2: Clinical Documentation: The patient was admitted to the hospital for an inpatient stay with severe abdominal pain. While in the hospital, the patient underwent a colonoscopy and partial resection of the colon. A large benign polyp was removed from ileocecal valve of the colon and submitted to pathology for evaluation. Type of Documentation Diagnosis(es) Procedure(s) Coding Classification System(s) Coding Guideline(s) and/or Conventions Scenario 3: Clinical Documentation: During a hiking trip, a patient fell and obtained a fracture of the left tibia. The patient was admitted and scheduled for a reduction of a displaced fracture with application of a cast. Type of Documentation Diagnosis(es) Procedure(s) Coding Classification System(s) Coding Guideline(s) and/or Conventions Scenario 4: Clinical Documentation: A patient with a diagnosis of gallstones was admitted to the Ambulatory Surgery Center for a laparoscopic cholecystectomy. The postoperative visit included a wound and dressing check with removal of a drain. The office visit and wound/dressing check along with the removal of a drain were not charged. Type of Documentation Diagnosis(es) Procedure(s) Coding Classification System(s) Coding Guideline(s) and/or Conventions Scenario 5: Clinical Documentation: Following evaluation in the Emergency Room, a patient was admitted to the hospital with chest pain. After study, it was determined that the patient had bilateral pneumonia. The patient was treated with antibiotics and respiratory therapy treatments and in 3 days was discharged to home. Type of Documentation Diagnosis(es) Procedure(s) Coding Classification System(s) Coding Guideline(s) and/or Conventions Scenario 6: Clinical Documentation: A young child with a persistent fever and left-sided earache presented to the physician’s office with the mother for evaluation. The patient was a new patient. The physician determined the patient had otitis media and prescribed ear drops and antibiotics with a planned follow-up visit in 10 days. Type of Documentation Diagnosis(es) Procedure(s) Coding Classification System(s) Coding Guideline(s) and/or Conventions

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