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CDIP Practice Exam 1 (2023 – 2024) Questions and Answers
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Assign code(s) for the following diagnosis: Congestive heart failure due to hypertension. I10 Essential (primary) hypertension I11.9 Hypertensive heart disease without heart failure I11.0 Hypertensive heart disease with heart failure I50.9 Heart failure, unspecified I50.1 Left ventricular failure I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure a.I10, I50. b.I11. c.I50.23, I d.I11.0, I50.9 - Answer - d Heart conditions are assigned a combination code when a causal relationship is stated (due to hypertension) or implied (hypertensive). Use an additional code to identify the type of heart failure in those patients with heart failure (ICD- 10 - CM Official Guidelines for Coding and Reporting 2016b, 41). Assign the best answer to complete the following sentence. The CPT codes for treatment of fractures: a.Use the terminology "manipulation" rather than "reduction" of fracture b.Include internal fixation in all codes c.Do not include application of cast d.Do not differentiate between open and closed treatment; CPT only specifies the site of the fracture - Answer - a Manipulation refers to the attempted reduction or restoration of a dislocated joint or fracture (Smith 2015, 84) In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, the coder would assign: a.Two CPT codes expressing each laceration repair b.One CPT code for the largest laceration c.One CPT code, adding the lengths of the lacerations together d.One CPT code for the most complex closure - Answer - c When multiple wounds are repaired with the same closure type (for example, simple), lengths of the wounds in the same classification and from all anatomical sites that are grouped together into the same code descriptor should be added together (Smith 2015, 67). Patient admitted for laparoscopic repair of right diaphragmatic hernia. Assign the ICD- 10 - PCS procedure code for this surgery. 0BQR4ZZ Repair right diaphragm, percutaneous endoscopic approach
0BQROZZ Repair right diaphragm, open approach 0BQS4ZZ Repair left diaphragm, percutaneous endoscopic approach 0BQSOZZ Repair left diaphragm, open approach a.0BQR4ZZ b.0BQR0ZZ c.0BQS4ZZ d.0BQS0ZZ - Answer - a Surgery is the only treatment for diaphragmatic hernias. ICD- 10 - PCS code 0BQR4ZZ, is used for laparoscopic repair of diaphragmatic hernia (Garvin 2015, 192, 284) When trying to determine if documentation is present to substantiate status asthmaticus, the coder should review the record for what terms and phrases? a.Intractable pneumonia b.Refractory asthma and severe, intractable wheezing c.Airway obstruction relieved by bronchodilators d.Limited but pronounced wheezing - Answer - b Status asthmaticus is defined as continual wheezing in spite of therapy (Leon-Chisen 2013, 230). Gastrointestinal bleeding can manifest as: a.Hematemesis, which indicates acute upper gastrointestinal hemorrhage b.Petechia c.Vomiting d.Constipation, which indicates upper or lower gastrointestinal hemorrhage - Answer - a Gastrointestinal bleeding manifests itself in several ways. These are hematemesis, melena, occult bleeding, hematochezia (Leon-Chisen 2013, 244). Which types of pacemaker devices have a unique ICD- 10 - PCS code. a.Dual chamber rate responsive b.Single chamber, single chamber rate responsive, and dual chamber c.Multiple chamber d.Multiple chamber rate responsive - Answer - b The three types of pacemakers are single chamber, single chamber rate responsive, and dual chamber. A single chamber uses a single lead; a dual chamber requires two leads, one in the atrium and one in the ventricle. The leads should also be coded (Leon-Chisen 2013, 416-418). Mechanical ventilation codes require consideration of which of the following? a.The time when a tracheal tube is inserted b.The replacement of an endotracheal tube c.The start time of endotracheal tube insertion followed by mechanical ventilation d.Mechanical ventilation during surgery - Answer - c Codes for mechanical ventilation indicate whether the patient was on mechanical ventilation for less than 24 hours, 24-96 consecutive hours and greater than 96 consecutive hours. The start time for calculating the duration begins with the start time of endotracheal tube insertion as the best method, followed by mechanical ventilation or the time that a patient who is on mechanical ventilation is admitted. The time ends with discontinuance of mechanical ventilation (Leon-Chisen 2013, 239-240).
d.None of the above - Answer - c ICD-10 Cerebral palsy and other paralytic syndromes (G80- G83) has additional specificity for spasticity as well as state of paralysis if any (AHIMA 2015, 23). A 90-year-old female was determined to have a CVA with hemorrhage. The cause of the hemorrhage was determined to be an embolism. What additionally could impact code assignment for the embolism code? a.Hematemesis b.Hypertension c.Site of the hemorrhage d.Seizure - Answer - c ICD-10 includes the site of the of the hemorrhage for increased specificity. If a patient undergoes a biopsy immediately before the definitive surgery for a frozen section, how should this be coded with ICD- 10 - PCS codes? a.The approach to the definitive surgery b.Suture method c.Exploratory surgery d.Open biopsy and definitive surgery - Answer - d The open biopsy is performed prior to the definitive surgery so that the pathologist can perform a frozen section of the tissue to determine malignancy. Approaches, suturing, and closure are not coded separately. Exploratory surgery is not coded when definitive surgery is performed (Leon-Chisen 2013, 92). A patient was admitted with diminished responsiveness and hypotension. The patient has a history of hypertension, CVA, CHF, and asthma. The patient suffered a cardiac arrest immediately following admission. The documentation within the record should: a.List hypotension as first-listed b.Include the reason for the cardiac arrest c.Include the date of the previous CVA d.Type of hypotension - Answer - b Instructional notes in ICD- 10 - CM for cardiac arrest states "code first underlying condition". Causes of nonpressure ulcers of the lower limb include: a.Varicose ulcers b.Chronic venous hypertension c.Diabetic ulcer d.All of the above - Answer - d The causes of lower limb ulcers include Atherosclerosis of lower extremity, Chronic venous hypertension, Diabetic ulcer, Postphlebitic syndrome, Postthrombotic syndrome, Varicose ulcer, and Other as specified (AHIMA 2015, 38). An 82-year-old female was walking and inadvertently twisted an ankle causing a minor fall. The patient suffered a fracture of the tibia. The patient was treated and released. It was discussed with the patient to take her hydrocodone as prescribed and continue her medications for osteoporosis, hypertension, and calcium. This fracture: a.is only a minor setback for the patient b.has Core measures to meet for quality
c.is coded as pathologic with osteoporosis d.is coded as a traumatic fracture - Answer - c Osteoporosis with current pathological fracture: A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone (ICD- 10 - CM Official Guidelines for Coding and Reporting 2016b, 51). A patient presented with pain in the right foot; right big toe. On physical exam, the toe was noted to be red and warm to touch. Laboratory findings show an elevated uric acid. The patient has a previous medication history of colchicine. Which diagnosis below was most likely listed in the diagnostic statement? a.Arthritis of the right toe b.Gout of the right toe c.Cellulitis of the right toe d.Elevated uric acid - Answer - b Gout inflammation of the joints. This is a metabolic disorder that in acute cases can cause some joints swell up become very painful. Crystals of uric acid that build up mostly in the joints cause the inflammation (NIH n.d.) This 75-year-old patient has a history of Alzheimer's disease. She is admitted with hypertensive encephalopathy with increased confusion. Her daughter states that she has noticed that she filled her once a day antihypertensive prescription 14 days ago and it still contains the original 30 tablets. This patient most likely could be queried for: a.Overdosing b.Underdosing c.A drug interaction d.Advancing Alzheimer's - Answer - b Using a prescribed medication less frequently than prescribed, in small doses, or not using the medication as instructed should be documented as "underdosing" by the provider (AHIMA 2015, 56) A patient was admitted with elevated white blood cells at 15.7 in the presence of cough and shortness of breath. Patient with a history of CHF on Lasix and COPD exhibiting symptoms of exacerbation with pulmonary edema along with crackles in the bases on exam with underlying infectious process, pneumonia. Chest x-ray shows left basilar infiltrate. The patient was started on antibiotic; azithromycin with Rocephin added. Physician lists CHF, pneumonia, COPD. In this example, pneumonia is the: a.Principal diagnosis b.Secondary diagnosis c.Query warranted d.Not enough information for assignment of a principal - Answer - a The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care." In this example, pneumonia is the principal based on presenting signs, symptoms, workup, and treatment (ICD- 10 - CM Official Guidelines for Coding and Reporting 2016b, 97) Based on the example above, the other/secondary diagnosis(es) would be: a.CHF, pneumonia
d.No additional documentation needed for reporting - Answer - a It is noted that the patient has a previous liver transplant and experiencing jaundice. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C. 19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider (ICD- 10 - CM Official Guidelines for Coding and Reporting 2016b, 52). When a patient is admitted for treatment of a secondary malignancy with an active primary site the principal diagnosis should be: a.The primary malignancy b.The secondary malignancy c.Either condition d.Query should be performed - Answer - b When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present (ICD- 10 - CM Official Guidelines for Coding and Reporting 2016b, 23). Assign the following diagnosis code: Permanent atrial fibrillation I47.2 Ventricular tachycardia I47.9 Paroxysmal tachycardia, unspecified I48.0 Paroxysmal atrial fibrillation I48.1 Persistent atrial fibrillation I48.2 Chronic atrial fibrillation a.I47. b.I47. c.I48. d.I48.2 - Answer - d In the ICD-10 alphabetic index, permanent atrial fibrillation is under the main term chronic atrial fibrillation. Atrial fibrillation can be permanent and medicines or other treatments can't restore normal heart rhythm (ICD- 10 - CM Official Guidelines for Coding and Reporting 2016b; NIH 2014). The Glasgow Coma Scale includes evaluation of: a.Eye opening response, verbal response, and motor response b.Visual response, verbal response, and motor response c.Eye opening response, verbal Response, and neurological response d.None of the above - Answer - a The Glasgow Coma Scale includes Eye Opening Response •Spontaneous-open with blinking at baseline 4 points •To verbal stimuli, command, speech 3 points •To pain only (not applied to face) 2 points •No response 1 point Verbal Response •Oriented 5 points •Confused conversation, but able to answer questions 4 points •Inappropriate words 3 points •Incomprehensible speech 2 points
•No response 1 point Motor Response •Obeys commands for movement 6 points •Purposeful movement to painful stimulus 5 points •Withdraws in response to pain 4 points •Flexion in response to pain (decorticate posturing) 3 points •Extension response in response to pain (decerebrate posturing) 2 points •No response 1 point When a patient has complete immobility due to severe physical disability or frailty it is called: a.paralysis b.quadriplegia c.functional quadriplegia d.debility - Answer - c Functional quadriplegia is the lack of ability to use one's limbs or to ambulate due to extreme debility. It is not associated with neurologic deficit or injury, should not be used for cases of neurologic quadriplegia. It should only be assigned if functional quadriplegia is specifically documented in the medical record (ICD- 10 - CM Official Guidelines for Coding and Reporting 2016b, 65). Severe sepsis with acute organ dysfunction requires a code for severe sepsis and: a.Specific organ dysfunction b.Underlying infection c.Sepsis only d.Multiple organ dysfunction - Answer - b The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection. Additional code(s) for the associated acute organ dysfunction are also required. Due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes (ICD- 10 - CM Official Guidelines for Coding and Reporting 2016b, 21). This root operation alters the diameter or route of a tubular body part and completely closes an orifice orlumen; for example, tubal ligation of Fallopian tubes. a.Dilation b.Ligation c.Occlusion d.Restriction - Answer - c Occlusion is applied to a procedure to close off a tubular body part or orifice via natural orifice or an artificially created orifice. Occlusion includes both intraluminal or extraluminal methods of closing off the body part (Leon-Chisen 2013, 98). The patient underwent laparotomy to determine if repair was needed to a patient's gastric bypass due to a fall later the day of procedure while in the hospital. No damage was identified and the wound was closed. The CDS is not sure what root operation to use. The most appropriate root operation would be: a.Inspection
a.XA, XB, XC, XD b.CC44, CC45, CC46, CC c.XE, XS, XP, XU d.44, 45, 45, 47 - Answer - c Modifiers, XE, XS, XP, XU, were created to be utilized in lieu of modifier 59 to provide increased specificity (CMS 2014a). E/M services refer to visits and consultations furnished by physicians and the following qualified NPPs: a.Physical therapists; clinical nurse specialists; certified nurse midwives; and physician assistants b.Nurse practitioners; clinical nurse specialists; certified nurse midwives; and physician assistants c.Speech therapists, clinical nurse specialists; certified nurse midwives; and physician assistants d.These services are furnished for physicians only - Answer - b E/M services refer to visits and consultations furnished by physicians and the following qualified NPPs: •Nurse practitioners; •Clinical nurse specialists; •Certified nurse midwives; and •Physician assistants. A NPP's Medicare benefit must permit him or her to bill for E/M services, and the services must be furnished within the scope of practice in the State in which the NPP practices in order to receive payment from Medicare (CMS 2015a). Every organization should develop a query policy and procedure that is specific to its organization and that addresses when to ask queries, who asks queries and to whom, the hospital's responsibility in supporting the query process, acceptable ways to respond to queries, and ___________ a.How to optimize revenue b.The physician's responsibility in responding to queries c.Number of queries to ask d.DRGs to target for revenue impact - Answer - b Every organization should develop a query policy and procedure that is specific to its organization and that addresses: •When to ask queries, •Who asks queries and to whom, •The hospital's responsibility in supporting the query process, •Acceptable ways to respond to queries, as well as the physician's responsibility in responding to queries Oversight of the CDI program should be comprised of the physician advisor or leader for clinical documentation and CDI, and the manager of the CDI program, along with: a.Executive leadership b.Service line directors c.Patient Financial Services d.Information Technology - Answer - a A CDI program should have support for physician advisor or leader for clinical documentation and CDI, and the manager of the CDI program, along with executive leadership (Hess 2015, 105).
Anywhere Hospital has been experiencing problems interacting with the medical staff. Anywhere should utilize which committee to assist with these problems? a.Compliance committee b.Executive committee c.Medical staff committee d.Oversight committee - Answer - a A CDI program should have support for physician advisor or leader for clinical documentation and CDI, and the manager of the CDI program, along with executive leadership (Hess 2015, 105). A new or restructuring CDI program should ask: a.How can the bottom line be increased? b.How many queries must be performed for financial success? c.Why does clinical documentation need to be improved? d.How fast can this be done? - Answer - c Understanding why a facility want to improve clinical documentation to support the vision of the program for all involved in the effort (Hess 2015, 205). A new CDI program is experiencing conflicts within the health record between a consulting physician and the physician ultimately responsible for the documentation of the patient. The physician ultimately responsible is the: a.Consulting physician b.Hospitalist c.Attending physician d.Intensivist - Answer - c The attending physicians are responsible for the documentation that supports the final diagnostic statement for the patient (42 CFR 412.46). The attending physician should be asked to provide the final documented response when inconsistencies arise within the record (42 CFR 412.46; Hess 2015, 29). Which of the following would generally be found in a query to a physician? a.Health record number and demographic information b.Name and contact number of the individual initiating the query and account number c.Date query initiated and date query must be completed d.Demographic information and name and contact number of individual initiating the query - Answer - b It is recommended that the healthcare entity's policy address the query format. A query generally includes the following information: patient name, admission date or date of service, health record number, account number, date query initiated, name and contact information of the individual initiating the query, and statement of the issue in the form of a question along with clinical indicators specified from the chart (for example, history and physical states urosepsis, lab reports WBC of 14,400, emergency department report fever of 102°F) (Shaw and Carter, 2014; Schraffenberger and Kuehn 2011, 45-46). In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed? a.Note the condition as present on admission
Communication within a CDI program is important from the very beginning. The three key concepts that should be considered in communication for the program are who communicates it, what is communicated, and_____: a.When is it communicated? b.How will it be communicated? c.How long will it be communicated? d.All of the above - Answer - b It is important to communicate information on the CDI process prior to starting or operationalizing a CDI program. Key concepts to cover are: •WHO communicates it—From whom will communications come? •HOW will it be communicated—What media will the CDI program use? •WHAT is communicated—What information will the CDI staff communicate? (Hess 2015,
To ensure a CDI program is successful and sustainable it should have: a.Physician leadership b.Metrics c.A CDI manager d.Resources such as CDI software - Answer - a Physician leadership is essential to a successful and sustainable CDI program (Marco and Buchman 2003; Keogh and Martin 2004; Hess 2015, 122). Dr. Bach has noted he has been increasingly negotiating problems between coders, CDS staff, and physicians. Dr. Bach stated he will no longer do this as this is not the role of the physician advisor: a.This is an accurate statement b.This is an inaccurate statement c.The CDI manager should begin to fill this role d.The HIM or coding manager should begin to fill this role - Answer - b It is important for the physician to undergo training and fully understand their role. The leader should be available to assist in particularly challenging reviews and when the CDI specialist encounters a problematic physician (Hess 2015, 122). The role of the physician advisor for CDI should require a minimum of: a.No formal training b.10 hours of training c.40 hours of training d.1 year of coding experience - Answer - c Physician advisors should participate in a minimum of 40 hours of training regarding CDI (Hess 2015, 124). Pat, the CDI manager at Uno Hospital, has hired 2 new CDS members. She wants to ensure they understand the standards of CDI internally and nationally. She could have them read and sign the: a.Uno HIPAA statement b.AHIMA Standards of Ethical Coding c.AHIMA Ethical Standards for Clinical Documentation Improvement (CDI) Professionals
d.Uno Memorandum of Understanding - Answer - c As stated by AHIMA, The AHIMA Code of Ethics (available on the AHIMA web site: http://www.ahima.org/about/ethics.asp) is relevant to all AHIMA members and credentialed HIM professionals and students, regardless of their professional functions, the settings in which they work, or the populations they serve. The AHIMA Ethical Standards for Clinical Documentation Improvement Professionals are intended to assist in decision making processes and actions, outline expectations for making ethical decisions in the workplace, and demonstrate the professionals' commitment to integrity. They are relevant to all clinical documentation improvement professionals and those who manage the clinical documentation improvement (CDI) function, regardless of the healthcare setting in which they work, or whether they are AHIMA members or nonmembers. Which of the following is an example of ethical issues related to coding? a.Inaccurate performance data b.Fraud and abuse c.Release of sensitive data d.Mistreatment of a vulnerable population - Answer - b Failure to heed the complex rules of coding for reimbursement can lead to problems with compliance and with fraud and abuse for the HIM professional (Harman 2013, 356). Terms synonymous with query are clarification, clinical clarification, documentation alert, and___________: a.Inquiry b.Documentation clarification c.None, query is the only term d.Physician inquiry - Answer - b Other terminology that means the same as query are clarification, clinical clarification, documentation alert, and documentation clarification (AHIMA 2014a, 4). The work and activities of the CDI professional should be tracked and monitored with a: a.Report b.Manager c.Quality assurance (QA) audit tool d.Performance improvement tool - Answer - c Monitoring a program can be vital for any process. Utilizing a Quality Assurance (QA) audit tool can ensure compliance and program success. (AHIMA 2014a, 6). Suggested key competencies for the CDI professional include all of the following except: a.Communication skills b.Leadership skills c.Persuasive personality d.Team player - Answer - c Finding the right person to be a part of a team can be difficult. Suggested key competencies for a CDI professional can include: •Financial knowledge •Clinical knowledge •Coding skills •Years of experience
d.a non-issue, as it never happens - Answer - c The most efficient way to capture retrospective queries is through the coding process Therefore, it is essential to have the coding staff interface with the CDI program staff. The coding staff should understand when there are outstanding concurrent queries upon discharge of the patient. The coding professional should generate a retrospective query to the physician so long as the justification for the query still exists when the patient is discharged (Hess 2015, 131). Physicians within this group are often considered top priority for CDI training: a.Oncologists b.Neurologists c.Hospitalists d.Cardiologists - Answer - c Physicians from the hospitalist group are often the top priority for CDI training in many organizations. Hospitalists often take on the role of the patient's primary care physician when a patient is hospitalized. Hospitalists should therefore have a predominant role in CDI training (Hess 2015, 146). The interactive process of utilizing a physician trainer to share experiences about clinical documentation with the trainees is: a.Asking b.Training c.Mastering d.Coaching - Answer - d Coaching is important for reinforcement and encouragement of participants within a CDI program. Experiences are shared, feedback is obtained and activities reinforced (Hess 2015, 147). The director of CDI and Coding is trying to improve communication between the CDI, physicians, and coding staff. A process is being developed to integrate the CDI model with the EHR to correspond with the physician for clarifications regarding documentation. This is called a: a.Electronic Query Process b.EHR innovation c.Electronic Documentation Integrity d.Meaningful Use - Answer - a The Electronic Query process is being utilized in many facilities to streamline the query process and make queries more readily accessible remotely (AHIMA 2014a, 5). A CDI program should have a.Training b.Physician advisor or champion c.Nurses or coders performing CDI review d.None of the above - Answer - b A physician advisor/champion should be officially designated as the physician leader for CDI (Hess 2015, 122). ABC Hospital has secured a consultant in making the decision to implement a CDI program. The consulting group has determined a CDI program can impact 70 percent of the MSDRG population and 90 percent of the medical staff could benefit from CDI initiatives. This analysis is
a.Not necessary in making a decision for CDI b.Important in assisting organizations in identifying potential benefits. c.Does not show impact of the need for CDI d.Unnecessary based on the needs - Answer - b Collecting complete and accurate data prior to program implementation can assist organizations in identifying potential benefits (AHIMA 2014a, 11). The first great challenge of a CDI program is to a.Persuade and have the full support of administration to implement and sustain the CDI program b.Find qualified staff for the program c.Engage medical staff d.Show quarterly return on investment - Answer - a The first great challenge of a CDI program is to persuade and have the full support of administration to implement and sustain the CDI program (AHIMA 2014a, 12). The CDS specialist, Gem, at ABC Hospital has had little success with several physicians responding to clinical validation queries. A colleague of Gem's mentioned she should share this process with her manager. The colleague most likely was referring to a.Clinical policy b.Query policy c.Escalation policy d.Physician Code of Ethics - Answer - c The AHIMA-developed Internal Escalation Policy includes sample policies that require a CDI specialist or coder to escalate issues regarding clinical documentation validity to a manager or steering committee (AHIMA 2013a, 1). A physician documents pneumonia of the left lower lobe with crackles in the bases. The patient has difficulty swallowing following day 2 of admission following CVA with infarct. The patient has a history of gastroesophageal reflux. It would be appropriate to query for: a.No query warranted b.Infectious pneumonia c.Aspiration pneumonia d.COPD with pneumonia - Answer - c When the documentation is not clear regarding the clinical significance of a potential complication, it is appropriate to query the physician (Garvin 2015; HHS 2014, Section LB. 16, 16; Leon-Chisen 2013, 43-44). Physician queries should: a.Be initiated on all admissions b.Be leading c.Be utilized to clarify ambiguous documentation d.Be performed by all health care professionals - Answer - c The generation of a query should be considered when the health record documentation is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent (AHIMA 2013b, 50-53). A CDI program should allow concurrent documentation review to: a.educate clinical care providers b.allow providers to clarify hospital acquired conditions and present on admission indicators
d.This is an appropriate query - Answer - d If there is evidence of a diagnosis within the medical record and the coder is uncertain whether it is a valid diagnosis because the documentation is incomplete, it is the coder's responsibility to query the attending physician to determine if this diagnosis should be included (Leon-Chisen 2013, 43-44). The following query was found in a patient's health record. Which of the answers best applies to this query? Dr. Bean: It is evident within the record that the patient has a diagnosis of CKD stage V. As the patient has a long history of diabetes and hypertension, please document this as the cause of the CKD in this patient on dialysis. a.This is a leading query b.This query brings in information not documented within the chart and is inappropriate c.This is a yes or no query d.This is an appropriate query - Answer - a When formulating a query, it is unacceptable to lead a provider to document a particular response. The query should not be directing or probing and the provider should not be led to make an assumption (Lovaasen and Schwerdtfeger 2011, 42; HHS 2014, Section I.B.16., 16). The following query was found in a patient's health record. Which of the answers best applies to this query? Dr. Bean: This patient was treated for both a primary neoplasm and a secondary neoplasm based on documentation with the record. Was the focus of the treatment the secondary neoplasm? a.This is a leading query b.This query brings in information not documented within the chart and is inappropriate c.This is a yes or no query d.This is an appropriate query - Answer - c If there is evidence of a diagnosis within the medical record and the coder is uncertain whether it is a valid diagnosis because the documentation is incomplete, it is the coder's responsibility to query the attending physician to determine if this diagnosis should be included (Leon-Chisen 2013, 43-44). An inpatient undergoes a procedure and has a postoperative complication during the hospitalization. The insurance company will not pay for the entire amount requested. Which POA indicator is likely part of the cause? a.N b.Y c.W d.U - Answer - a The postoperative complication that is not present at admission. The insurance company may not pay for the services provided to take care of the postoperative complication (Garrett 2009, 11). When trying to determine if documentation is present to substantiate status asthmaticus, the coder should review the record for what terms and phrases? a.Intractable pneumonia b.Refractory asthma and severe, intractable wheezing c.Airway obstruction relieved by bronchodilators
d.Limited but pronounced wheezing - Answer - b Status asthmaticus is defined as continual wheezing in spite of therapy (Leon-Chisen 2013, 230). Within the postoperative patient, this is the most common type of shock. It occurs when large amounts of fluids are lost from hemorrhage or severe dehydration. a.Cardiogenic b.Renal c.Hypovolemic d.Neurologic - Answer - c Hypovolemic shock is the most common type of shock seen in the postoperative patient. It occurs when large amounts of fluids are lost from hemorrhage or severe dehydration (AHA 2011, 150). The procedure that was performed for the definitive treatment (rather than the diagnosis) of the main condition, or a complication of the condition is the: a.Chief procedure b.Principal treatment c.Principal procedure d.Comorbidity - Answer - c The principal procedure is the procedure that was performed for the definitive treatment (rather than the diagnosis) of the main condition or a complication of the condition (Shaw and Carter 2014; LaTour et al. 2013, 432,940). A physician query may not be appropriate in which of the following instances? a.Diagnosis of viral pneumonia noted in the progress notes and sputum cultures showing Haemophilus influenzae b.Discharge summary indicates chronic renal failure but the progress notes document acute renal failure throughout the stay c.Acute respiratory failure in a patient whose lab report findings appear to not support this diagnosis d.Diagnosis of chest pain and abnormal cardiac enzymes indicative of an AMI - Answer - c A query may not be appropriate because the clinical information or clinical picture does not appear to support the documentation of a condition or procedure. In situations in which the provider's documented diagnosis does not appear to be supported by clinical findings, a healthcare entity's policies can provide guidance on a process for addressing the issue without querying the attending physician (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 348). Who is responsible for the content, quality, and signing of the discharge summary? a.Attending physician b.Head nurse c.Consulting physician d.Admitting nurse - Answer - a The physician principally responsible for the patient's hospital care generally dictates the discharge summary. However, a resident, physician assistant, or nurse practitioner who is being supervised by the attending physician may complete this task. Regardless of who documents it, the attending physician is responsible for the content and quality of the summary and must date and sign it Shaw and Carter 2014; Fahrenholz and Russo 2013, 284).
