Clinical Documentation & Record Analysis Flashcards

When reviewing an operative report for coding purposes, which element is most critical for assigning the correct procedure code?

Answer: The post-operative diagnosis and description of the procedure performed

The post-operative diagnosis and the detailed description of the procedure performed are the most critical elements, as the actual findings may differ from the pre-operative diagnosis.

A pathology report confirming malignancy is received after the patient has been discharged. The attending physician documented 'suspected carcinoma' in the discharge summary. How should the diagnosis be coded?

Answer: Code the confirmed malignancy based on the pathology report

Per ICD-10-CM guidelines, when a pathology report confirms a diagnosis after discharge, the confirmed diagnosis should be coded rather than the uncertain term.

Which of the following best describes the purpose of the History and Physical (H&P) in the medical record?

Answer: To document the patient's medical history, review of systems, and baseline physical examination at admission

The History and Physical documents the patient's past medical history, current complaint, review of systems, and the physician's baseline examination findings at or near the time of admission.

In the context of clinical documentation improvement (CDI), which type of query format asks the physician to choose from a list of clinically supported options?

Answer: Multiple choice query

A multiple choice query presents the physician with clinically supported diagnostic options to choose from, along with space to add an unlisted response, making it compliant and efficient.

Which health record document would a coder primarily reference to assign CPT codes for surgical procedures performed in the operating room?

Answer: Operative report

The operative report, dictated by the surgeon, describes the procedure performed in detail and is the primary source for assigning surgical CPT procedure codes.

A coder notices that a physician documented 'acute respiratory failure' in the progress notes but did not include it in the discharge summary. What is the appropriate action?

Answer: Query the physician to confirm whether acute respiratory failure should be included as a final diagnosis

When a significant diagnosis appears in progress notes but is absent from the discharge summary, the coder should query the physician to confirm whether it should be included as a final diagnosis.

Which of the following represents the correct hierarchy of source documents when conflicting information exists for determining the principal procedure on an inpatient claim?

Answer: Operative report, then procedure notes, then discharge summary

The operative report is the most authoritative source for surgical procedures, followed by procedure notes, then the discharge summary when discrepancies exist.