CCS Clinical Documentation & Record Analysis

Question 1

Which document in the health record serves as the primary source for assigning the principal diagnosis in an inpatient stay?

Accepted Answer

Physician's discharge summary

Answer

The physician's discharge summary provides a comprehensive account of the entire hospital stay and is the primary source for principal diagnosis assignment.

Question 2

According to the Uniform Hospital Discharge Data Set (UHDDS), the principal diagnosis is defined as the condition established after study to be chiefly responsible for what?

Accepted Answer

Occasioning the admission to the hospital

Answer

The UHDDS defines the principal diagnosis as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital.

Question 3

When a patient's record contains conflicting documentation between the attending physician and a consulting specialist regarding a diagnosis, what should the coder do?

Accepted Answer

Query the attending physician for clarification

Answer

When documentation is conflicting or ambiguous, the coder should query the attending physician (who is responsible for the patient's care) for clarification before assigning codes.

Question 4

Which of the following is the most appropriate use of a physician query?

Accepted Answer

To clarify ambiguous or incomplete documentation that impacts code assignment

Answer

Physician queries are appropriate only to clarify ambiguous or incomplete documentation; they must never be leading or designed to influence reimbursement.

Question 5

What does the term 'present on admission' (POA) indicator primarily help distinguish?

Accepted Answer

Whether a condition existed at the time of inpatient admission versus developed during the stay

Answer

The POA indicator identifies whether a condition was present at the time of inpatient admission, which helps distinguish hospital-acquired conditions from pre-existing ones.

(CCS) Certified Coding Specialist Practice Test

(CCS) Certified Coding Specialist Practice Test

CCS Clinical Documentation & Record Analysis