Patient Assessment & Documentation Flashcards

A Medicare Advantage plan requests clinical documentation to support a prior authorization for an MRI. Which element of the medical record is MOST critical to establish medical necessity?

Answer: Physician's clinical notes documenting symptoms, examination findings, and rationale for imaging

Medical necessity for prior authorization is established through clinical documentation showing the patient's symptoms, objective findings, and the physician's clinical rationale.

Under the Medicare Conditions of Participation, how soon after admission must a physician complete the History & Physical (H&P) for an inpatient?

Answer: Within 24 hours

CMS Conditions of Participation require the History & Physical to be completed and placed in the medical record within 24 hours of inpatient admission.

Which functional assessment tool is required by CMS as part of the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)?

Answer: FIM (Functional Independence Measure)

The IRF-PAI uses the Functional Independence Measure (FIM) instrument to assess a patient's level of disability and functional ability in an inpatient rehab setting.

A CMS audit finds that a home health agency billed for skilled nursing visits but documentation only showed 'patient doing well, no complaints.' What is the primary compliance concern?

Answer: Lack of documentation supporting the skilled nature of the services provided

Medicare requires documentation to demonstrate the skilled, professional judgment involved in each nursing visit; generic notes fail to justify that a skilled nurse's expertise was required.

Which coding guideline applies when a Medicare patient is admitted with a condition that was suspected but later found to be absent at discharge?

Answer: Code the suspected condition as if it were confirmed for inpatient records

For inpatient records, ICD-10-CM guidelines allow coding of uncertain diagnoses (suspected, possible, probable) if no definitive diagnosis is established by discharge.

A Medicare patient refuses to sign the required election statement for hospice. What should the hospice provider do to maintain compliance?

Answer: Document the refusal and obtain signature from the healthcare proxy or legal representative

If a patient cannot or will not sign, the legal representative or healthcare proxy must sign the election statement; the reason for the representative's signature should be documented.

What does 'present on admission' (POA) indicator 'U' mean when reported on a Medicare inpatient claim?

Answer: Documentation is insufficient to determine if the condition was present at admission

POA indicator 'U' means the documentation is insufficient to determine whether the condition was present at the time of inpatient admission.