Documentation & Record Keeping Flashcards
7 cards from real ADM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation & Record Keeping flashcards as text
Which statement about co-occurring disorder documentation is MOST accurate for addiction medicine practice?
Answer: Both the SUD and psychiatric diagnoses should be coded and documented to reflect the full clinical picture
Comprehensive documentation of all co-occurring conditions is essential for accurate coding, treatment planning, and continuity of care.
When documenting informed consent for naltrexone extended-release injection, which element is ESSENTIAL to include?
Answer: Discussion of risks, benefits, alternatives, and patient questions addressed
Informed consent documentation must capture the core elements: risks, benefits, alternatives, and confirmation that patient questions were answered.
A new 2024 update to 42 CFR Part 2 allows SUD records to be shared more freely for which purpose?
Answer: Integrated care and care coordination with patient consent via a single general consent
The 2024 revised rule aligns Part 2 more closely with HIPAA, allowing a single patient consent to cover treatment, payment, and healthcare operations disclosures.
For a methadone take-home dose, documentation should include all of the following EXCEPT:
Answer: Patient's credit score and financial status
Take-home documentation requires clinical rationale, stability criteria, quantity, and date — financial information is not a required documentation element.
Which ICD-10-CM code modifier indicates 'in sustained remission' for an alcohol use disorder diagnosis?
Answer: .21 (In sustained remission)
The '.21' modifier (e.g., F10.21) specifies alcohol use disorder in sustained remission per ICD-10-CM coding conventions.
Which documentation practice BEST supports medical necessity for continued MOUD when utilization review requests it?
Answer: Ongoing ASAM dimension assessments showing persistent risk without medication
Ongoing ASAM-based assessments demonstrating continued clinical need provide the strongest medical necessity justification for insurers.
A patient requests amendment of their SUD treatment record under HIPAA. The provider may DENY the request if:
Answer: The record was not created by that provider or the information is accurate and complete
HIPAA permits denial of amendment requests when the record was not created by the covered entity or when the information is deemed accurate and complete.