Healthcare Documentation Flashcards

A patient is treated for both community-acquired pneumonia and COPD exacerbation during the same admission. How should this be documented?

Answer: Both conditions should be documented with the one most responsible for the admission as principal

Both conditions may be coded; the one established after study as chiefly responsible for the admission is sequenced as principal per UHDDS guidelines.

What is the primary purpose of a compliant physician query in clinical documentation improvement?

Answer: To clarify or obtain additional clinical information to ensure accurate and complete documentation

A compliant query seeks clarification of ambiguous or incomplete documentation to ensure accuracy, not to lead the physician toward a specific answer.

Which scenario represents an appropriate use of a verbal query according to AHIMA/ACDIS guidelines?

Answer: An urgent situation where a delayed written query would affect patient care or timely billing

Verbal queries are appropriate only when urgency exists and the query must be documented in the medical record with the physician's response.

In the context of present on admission (POA) indicators, which condition would be assigned a POA indicator of 'N'?

Answer: A pressure injury that developed two days after admission

A POA indicator of 'N' is assigned when the condition was not present at the time of admission, such as a hospital-acquired condition.

A CDS reviews a record where the physician has documented 'possible sepsis.' Under ICD-10-CM inpatient coding guidelines, how should this be coded?

Answer: Code sepsis as if it were confirmed, per inpatient uncertain diagnosis guidelines

ICD-10-CM inpatient guidelines allow coding of uncertain diagnoses such as 'possible,' 'probable,' or 'suspected' as if confirmed at the time of discharge.

Which element of the H&P most directly supports documentation of a patient's chronic conditions for HCC risk adjustment?

Answer: The past medical history and active problem list

The past medical history and active problem list document chronic conditions that, when addressed during the encounter, support HCC risk adjustment coding.

A patient with type 2 diabetes is admitted for a diabetic foot ulcer with peripheral angiopathy. What documentation is needed to capture the highest specificity?

Answer: Document the causal relationship between diabetes, peripheral angiopathy, and the ulcer, including ulcer site and severity

ICD-10-CM combination codes for diabetic complications require documented linkage between diabetes and the complication, plus ulcer site and severity for complete specificity.