CCS Clinical Documentation & Record Analysis 2

Question 1

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

Accepted Answer

The post-operative diagnosis and description of the procedure performed

Answer

The pre-operative diagnosis

Answer

The anesthesia type used

Answer

The estimated blood loss documented

Question 2

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?

Accepted Answer

Code the confirmed malignancy based on the pathology report

Answer

Code the uncertain term 'suspected carcinoma'

Answer

Query the physician before coding either diagnosis

Answer

Code only the signs and symptoms

Question 3

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

Accepted Answer

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

Answer

To summarize the hospital course and outcomes at discharge

Answer

To record nursing assessments completed throughout the stay

Answer

To outline the discharge plan and follow-up instructions

Question 4

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?

Accepted Answer

Multiple choice query

Answer

Open-ended query

Answer

Yes/No query

Answer

Retrospective query

Question 5

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

Accepted Answer

Operative report

Answer

Anesthesia record

Answer

Recovery room notes

Answer

Pre-operative nursing checklist

Question 6

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?

Accepted Answer

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

Answer

Code the acute respiratory failure from the progress notes without further action

Answer

Ignore the progress note finding and code only what is in the discharge summary

Answer

Code the acute respiratory failure as a secondary diagnosis automatically

Question 7

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

Accepted Answer

Operative report, then procedure notes, then discharge summary

Answer

Nursing notes, then operative report, then discharge summary

Answer

Discharge summary, then nursing notes, then operative report

Answer

Physician orders, then discharge summary, then operative report