Patient Assessment & Documentation Flashcards
7 cards from real CMS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Assessment & Documentation flashcards as text
Under Medicare's 2-midnight rule, which documentation element is MOST critical for supporting an inpatient admission rather than an observation stay?
Answer: Physician's expectation that the patient requires hospital care spanning two midnights
The 2-midnight rule requires physician documentation of a reasonable expectation that medically necessary care will span at least two midnights to justify inpatient status.
A Medicare patient's record shows a diagnosis of Type 2 diabetes with diabetic nephropathy. How should this be coded according to ICD-10 guidelines?
Answer: E11.65 as a combination code
ICD-10-CM provides combination code E11.65 (Type 2 diabetes mellitus with hyperglycemia) — diabetic nephropathy is captured with E11.65 or E11.6x codes combining both conditions.
Which Medicare-required document must be given to a beneficiary BEFORE a service is rendered when Medicare may not cover it?
Answer: Advance Beneficiary Notice of Noncoverage (ABN)
The ABN must be issued before a service is provided if there is reason to believe Medicare will not cover it, so the beneficiary can decide whether to proceed and pay out of pocket.
When documenting a Medicare Annual Wellness Visit (AWV), which element is REQUIRED but is NOT required for a traditional E/M visit?
Answer: Personalized prevention plan and health risk assessment
The AWV specifically requires a Health Risk Assessment (HRA) and a written Personalized Prevention Plan, elements not mandated for standard E/M visits.
A skilled nursing facility patient's MDS assessment shows a BIMS (Brief Interview for Mental Status) score of 7. What does this indicate?
Answer: Severe cognitive impairment
A BIMS score of 0–7 indicates severe cognitive impairment; scores 8–12 indicate moderate, and 13–15 indicate intact cognition.
For Medicare home health coverage, documentation must support that the patient is 'homebound.' Which scenario does NOT meet the homebound definition?
Answer: Patient attends religious services once a week without significant taxing effort
Homebound status allows infrequent absences for medical appointments or rare non-medical events, but regular non-medical outings without considerable effort disqualify a patient.
What is the required timeframe for a physician to sign a verbal order documented in a Medicare patient's home health record?
Answer: Within 48 hours
CMS requires verbal orders for home health to be authenticated (signed) by the physician within 48 hours to meet Conditions of Participation.