CCDS Healthcare Documentation 5 — Questions and Answers
Question 1: A patient is treated for both community-acquired pneumonia and COPD exacerbation during the same admission. How should this be documented?
- Only the pneumonia should be documented as it is more acute
- Both conditions should be documented with the one most responsible for the admission as principal (Correct answer)
- COPD exacerbation should always be the principal diagnosis when present
- The physician should combine them into a single diagnosis
Correct 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.
Question 2: What is the primary purpose of a compliant physician query in clinical documentation improvement?
- To instruct the physician to add diagnoses that increase reimbursement
- To clarify or obtain additional clinical information to ensure accurate and complete documentation (Correct answer)
- To challenge the physician's clinical judgment
- To satisfy payer audit requirements retroactively
Correct 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.
Question 3: Which scenario represents an appropriate use of a verbal query according to AHIMA/ACDIS guidelines?
- Routine clarification of a diagnosis that can wait until discharge
- An urgent situation where a delayed written query would affect patient care or timely billing (Correct answer)
- When the CDS prefers verbal communication over written forms
- When the physician is known to ignore written queries
Correct 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.
Question 4: In the context of present on admission (POA) indicators, which condition would be assigned a POA indicator of 'N'?
- A UTI documented at the time of admission
- A pressure injury that developed two days after admission (Correct answer)
- Chronic hypertension noted in the history and physical
- A fracture that was the reason for admission
Correct 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.
Question 5: A CDS reviews a record where the physician has documented 'possible sepsis.' Under ICD-10-CM inpatient coding guidelines, how should this be coded?
- Code the signs and symptoms of sepsis only, as the diagnosis is not confirmed
- Code sepsis as if it were confirmed, per inpatient uncertain diagnosis guidelines (Correct answer)
- Query the physician to confirm or rule out sepsis before coding
- Assign a code for 'suspected infection' instead
Correct 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.
Question 6: Which element of the H&P most directly supports documentation of a patient's chronic conditions for HCC risk adjustment?
- The review of systems section
- The past medical history and active problem list (Correct answer)
- The physical examination findings
- The assessment and plan for the acute complaint only
Correct 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.
Question 7: 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?
- Document diabetes and foot ulcer as separate, unrelated conditions
- Document the causal relationship between diabetes, peripheral angiopathy, and the ulcer, including ulcer site and severity (Correct answer)
- Document only the ulcer since it is the reason for admission
- Document peripheral vascular disease without linking it to diabetes
Correct 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.
CCDS Healthcare Documentation 5
A patient is treated for both community-acquired pneumonia and COPD exacerbation during the same admission.
How should this be documented?