CCDS Healthcare Documentation 2

Question 1

Which of the following is considered a 'qualified provider' who may document diagnoses for ICD-10-CM coding purposes in the inpatient setting?

Accepted Answer

Attending physician or other qualified healthcare practitioner legally accountable for the patient's care

Answer

Registered nurse documenting in the nursing care plan

Answer

Physical therapist documenting in the rehabilitation notes

Answer

Pharmacist documenting in the medication reconciliation record

Question 2

A discharge summary that conflicts with the body of the medical record should be handled in which of the following ways?

Accepted Answer

Query the physician to resolve the discrepancy before finalizing the coded record

Answer

Always defer to the discharge summary as the most authoritative document

Answer

Code based on whichever documentation supports the higher DRG

Answer

Use the conflicting information to code two separate diagnoses

Question 3

Which of the following documentation elements is REQUIRED by CMS Conditions of Participation for all inpatient medical records?

Accepted Answer

Authenticated history and physical completed within 24 hours of admission or prior to surgery

Answer

Nutritional assessment completed within 24 hours of admission

Answer

Daily physician progress notes co-signed by the attending

Answer

Nursing care plan updated every shift for the entire hospitalization

Question 4

A physician uses the term 'urosepsis' in documentation. How should a CDI specialist respond?

Accepted Answer

Query the physician to clarify whether a UTI, sepsis due to UTI, or another condition is intended

Answer

Code as sepsis due to urinary tract infection directly

Answer

Accept the term and code as unspecified sepsis (A41.9)

Answer

Document that urosepsis is the principal diagnosis without further review

Question 5

Under HIPAA, which role has the authority to release a patient's medical records to a CDI specialist for documentation review?

Accepted Answer

The CDI specialist has inherent access as a member of the healthcare operations team

Answer

Any hospital employee who requests access for quality improvement

Answer

Only the patient's attending physician after written patient authorization

Answer

The hospital compliance officer upon receipt of a formal written request

Question 6

Which element of a physician's documentation would MOST clearly support coding of a complication of care in the inpatient setting?

Accepted Answer

An attending physician's progress note stating 'patient developed postoperative wound infection'

Answer

A nurse's incident report documenting a medication administration error

Answer

A pharmacist's note identifying a potential drug interaction

Answer

A radiology report describing a finding consistent with a wound complication