Q: I am never sure of correct sequencing when the admission is for flu, pneumonia, and asthma. The patient presented in the emergency department (ED) with shortness of breath, still tight after nebulizer treatment in the emergency room. The patient was kept for observation for one day, then was admitted. Documentation includes: Fever 101.8 in ED; respiratory rate (RR) 24; white blood cell count (WBC) 12.6 Influenza and upper respiratory tract infection Mild persistent asthma in exacerbation due to the above (wheezing, tachycardia in the ED, 130s); acute hypoxic respiratory failure (PO 90%). Superimposed RLL community-acquired pneumonia (CAP), per chest x-ray Can you suggest proper sequencing and if queries are needed?
Since the physician doesn't need to document a specific root operation, coders cannot rely solely on the terms the physician uses; thus it is important for each coder to fully understand each definition, including the root operations that put in, put back, or move some or all of a body part.
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