CMS Patient Assessment & Documentation 3 — Questions and Answers
Question 1: Under Medicare's 2-midnight rule, which documentation element is MOST critical for supporting an inpatient admission rather than an observation stay?
- The patient's copay amount
- Physician's expectation that the patient requires hospital care spanning two midnights (Correct answer)
- Social work discharge planning notes
- Nursing assessment flowsheets
Correct 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.
Question 2: 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?
- E11.9 and N18.9 separately
- E11.65 as a combination code (Correct answer)
- N18.9 only, as the more severe condition
- E11.9 with an external cause code
Correct 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.
Question 3: Which Medicare-required document must be given to a beneficiary BEFORE a service is rendered when Medicare may not cover it?
- Medicare Summary Notice (MSN)
- Advance Beneficiary Notice of Noncoverage (ABN) (Correct answer)
- Explanation of Benefits (EOB)
- Notice of Exclusions from Medicare Benefits (NEMB)
Correct 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.
Question 4: When documenting a Medicare Annual Wellness Visit (AWV), which element is REQUIRED but is NOT required for a traditional E/M visit?
- Review of current medications
- Personalized prevention plan and health risk assessment (Correct answer)
- Documentation of vital signs
- Review of past medical history
Correct 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.
Question 5: A skilled nursing facility patient's MDS assessment shows a BIMS (Brief Interview for Mental Status) score of 7. What does this indicate?
- Intact cognition
- Moderate cognitive impairment
- Severe cognitive impairment (Correct answer)
- Mild cognitive impairment
Correct 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.
Question 6: For Medicare home health coverage, documentation must support that the patient is 'homebound.' Which scenario does NOT meet the homebound definition?
- Patient uses a wheelchair and leaving home requires considerable effort
- Patient attends religious services once a week without significant taxing effort (Correct answer)
- Patient leaves home only for medical appointments
- Patient has a condition such that leaving home is medically contraindicated
Correct 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.
Question 7: What is the required timeframe for a physician to sign a verbal order documented in a Medicare patient's home health record?
- Within 24 hours
- Within 48 hours (Correct answer)
- Within 30 days
- Within the certification period
Correct 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.
CMS Patient Assessment & Documentation 3
Under Medicare's 2-midnight rule, which documentation element is MOST critical for supporting an inpatient admission rather than an observation stay?