CMS Patient Assessment & Documentation 3

Question 1

Under Medicare's 2-midnight rule, which documentation element is MOST critical for supporting an inpatient admission rather than an observation stay?

Accepted Answer

Physician's expectation that the patient requires hospital care spanning two midnights

Answer

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?

Accepted Answer

E11.65 as a combination code

Answer

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?

Accepted Answer

Advance Beneficiary Notice of Noncoverage (ABN)

Answer

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?

Accepted Answer

Personalized prevention plan and health risk assessment

Answer

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?

Accepted Answer

Severe cognitive impairment

Answer

A BIMS score of 0–7 indicates severe cognitive impairment; scores 8–12 indicate moderate, and 13–15 indicate intact cognition.

(CMS) Certified Medicare Specialist Practice Test

(CMS) Certified Medicare Specialist Practice Test

CMS Patient Assessment & Documentation 3