481707 documentation query form...which suggests division of abdominal adhesions. title 481707...
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ERYURN: .......................................................................................................
Episode: ..................................................................................................
Patient Name: .........................................................................................
Date of Birth: ............................................Sex: ........................................
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Attach patient identification label
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UPLiftGroup Health Information Specialists
DOCUMENTATION QUERY
Clinician: ________________________________________ Speciality: ____________________ Ward:
Admission date: _____ /_____ /_____ to _____ /_____ /_____
Your clinical judgement is required to clarify the following to support accurate and complete documentation,
clinical classification, and reporting requirements.
Details / further comments:
Print Name:
HIM / CDS / Clinical Coder: Signature: Date: _____ /_____ /_____
Method of Contact: E-mail Phone Fax Meeting
481707 Documentation Query Form.indd 1 5/8/20 4:10 pm
b. Noc. Other (please specify)d. Unable to clinically determine
Clinician Signature: Designation: Date: _____ /_____ /_____
Dear
a. Yes
If possible, can you please clarify whether this operation included division of adhesions? However, there is no text in the operation body describing adhesiolysis to allow for code assignment.
The operation report for this patient’s documents MBS item which suggests division of abdominal adhesions.
UR Number: Name: Gender: Episode: Ward: Clinician: Admission Date to: Admission Date from: Text Field 11: Text Field 12: Text Field 13: Text Field 14: Date of Birth: Speciality: Print name: Date 5: Date 3: Meeting: OffFax: OffPhone: OffEmail: OffHIM CDS: Text2: Text3: Insert Operation: