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 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.

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

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.

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

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.

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

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.

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

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

(CCS) Certified Coding Specialist Practice Test

(CCS) Certified Coding Specialist Practice Test

CCS Clinical Documentation & Record Analysis 2