CCDS Healthcare Documentation 5

Question 1

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

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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'?

Accepted Answer

A pressure injury that developed two days after admission

Answer

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?

Accepted Answer

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

Answer

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

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Healthcare Documentation 5