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Documentation & Coding Standards –
Complete Guide & Exam Prep (2026– 2027 )
hospital IP record - correct answers - medical record physician's office record - correct answers - patient record long-term care record - correct answers - resident record behavioral health facilities and clinics - correct answers - client record corrections in health record - correct answers - strike through the incorrect information with a single line, add date and first initial and last name of person making the correction. Add the additional/correct information data - correct answers - objective descriptions of processes and procedures. Observable events representing facts such as ht, wt, temperature. Analysis of data collected for a specific purpose provides info regarding pt's condition information - correct answers - administrative information and demographic data. Pt's full name, address, phone #, ethnicity, marital status, dob, place of birth, ss#, name & contact info for next of kin
Uniform Hospital Discharge Data Set - UHDDS - correct answers - personal pt identifier, dob, sex, race, ethnicity, residence, hospital ID, admit date, type of admission, discharge date, attending physician's ID, operating physician ID, principal dx, other dx, external cause of injury codes, birth wt of neonates, procedures and dates, disposition of pt, expected payment source, total charges Master Pt Index - MPI - correct answers - db which includes information for ea pt. Used to track pt. --internal pt ID determined by facility, pt name, dob, gender, race, ethnicity, address, previous name(s)/alias, ss#, acct #, admission date, d/c date, service type, pt disposition (d/c status) Minimum Data Set - MDS - correct answers - required by CMS for nursing facilities. A tool that can be used to implement standardized assessments and mgmt of care. A mandated process for all residents in a M/Care or M/Caid certified nursing facility Data Mining - correct answers - process to identify trends and patterns in a db. Can be useful in many ways including detecting fraud and abuse and identifying effective treatments and efficiencies. legal health record - correct answers - the official business record created by the healthcare organization. The portion of the health record that will be disclosed when requested by parties outside the organization of record. legal health record - correct answers - must meet accepted standards of documentation as defined by CMS' Conditions of Participation (CoP), Conditions of Coverage (CfC), federal regulation, state laws and accrediting agencies such as Joint Commission.
3 --Facilitate claims review and payments 4 --Assist in utilization review and quality of care evals 5 --Reduce complicated medical reviews 6 --Provide clinical data for research and education 7 --Serve as legal document to verify services payers look at documentation for - correct answers - 1 --appropriateness of treatment to pt condition 2 --Medical necessity for dx and/or tx of illness 3 --Coded correctly 4 --Reported correctly for site of service Conditions of Participation (CoP) Conditions for Coverage (CfC) - correct answers - standards are set forth by Federal Register standards must be met in order to participate in M/Care or M/Caid programs. They include guidelines for documentation and apply to hospitals and ASCs two categories of documentation standards - correct answers - patient-specific data and information additional standards for specific pt populations (invasive procedures, amb care, emergency, addictions) pt specific data - correct answers - applies to all pts, inpts or outpts, and where the add'l standards apply to its who fit the specific criteria
specific documentation requirements - correct answers - pt demographics reason for care, treatment or service evidence of informed consent evidence of known advance directives legal status of pts receiving behavioral health services emergency care, treatment/services provided documentation of findings MAC - correct answers - Medicare Administrative Contractor principal diagnosis - correct answers - that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care circumstances of the inpt admission - correct answers - always governs the selection of the principal dx selection of principal diagnosis - correct answers - based on interpretation of what was treated or evaluated. May not always be the most significant condition of the patient. sequencing of diagnoses (to determine MS-DRG) - correct answers - 1 --principal diagnosis 2 --complications 3 --comorbidity
"still to be ruled out" or other terms indicating uncertainty, code the condition as if it existed or was established. Basis = the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis. NOTE: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals MS-DRG - correct answers - Medicare Severity Diagnosis Related Groups Principal Procedure - correct answers - that which was performed for definitive treatment rather than for diagnostic or exploratory purposes or for treatment of a complication. significant procedure - correct answers - 1 --surgical in nature 2 --Carries a procedural risk 3 --Carries an anesthetic risk 4 --Requires specialized training more than one principle procedure - correct answers - when > 1 procedure is done and both meet criteria for the principal px...the one that is most closely related to the principal dx should be coded as the principal px, followed by the remaining procedures. E&M services on inpts - correct answers - H&P, progress notes, consultations and d/c summaries. Each includes an evaluation of the pt and plan of care
HPI - correct answers - chronological description of the development of the pt's present illness from the first sign or symptom or from the previous encounter to the present ROS - correct answers - an account of body systems obtained through a series of questions seeking to spot signs/symptoms that the pt may be experiencing or has experienced Past history - correct answers - pt's experiences with childhood diseases, illnesses, operations, injuries, treatments, allergies and medications. When pt's past history is pertinent to the current condition, history dx codes are reported. Family history - correct answers - review of medical events in pt's family, including age of death and diseases which may be hereditary or which place the pt at an increased risk. When pt's family history is relevant to the current condition, you can code it Social history - correct answers - includes pt's use of tobacco, alcohol/drugs, occupation and marital status. Should be age appropriate. Physical exam - correct answers - done by provider. Exam of body areas or organ systems. Extent of exam is determined by pt's condition. assessment / impression / diagnoses - correct answers - includes all conditions, diseases, signs/symptoms that are being treated or monitored.
