Clinical Documentation, Provider Queries and Compliance Flashcards

When is a provider query appropriate?

Answer: When documentation is conflicting, incomplete, ambiguous or unclear

Queries clarify conflicting, incomplete, ambiguous or unclear documentation so the record shows the patient's condition accurately. They must never be used only to raise payment.

Which of these makes a query non-compliant (leading)?

Answer: Mentioning the financial impact of the answer

AHIMA/ACDIS query guidance says queries must not mention financial or quality-score impact and must not steer the provider toward a particular diagnosis.

A lab report shows low sodium, but the provider has not documented hyponatremia. What should the coder do?

Answer: Not assign the code; query the provider if the finding seems clinically significant

Coders cannot assign a diagnosis from lab values alone. The provider must document it. If the finding seems clinically significant, a query is appropriate.

Which BMI-related item may come from documentation by a clinician other than the patient's provider, such as a dietitian?

Answer: The BMI value itself

Under the Official Guidelines, BMI, pressure ulcer stage and some similar details may come from other clinicians. The associated diagnosis, such as obesity, must be documented by the patient's provider.

Under HIPAA transaction code-set rules, ICD-10-PCS is required for reporting which services?

Answer: Inpatient hospital procedures

HIPAA requires ICD-10-CM for diagnoses in all settings and ICD-10-PCS only for inpatient hospital procedures. Outpatient and physician procedures use CPT/HCPCS.

When may a yes/no query be used?

Answer: To confirm documented information or settle conflicts such as POA status, not to establish a new diagnosis

Under industry query guidance, yes/no queries should not be used to establish a new diagnosis. They are acceptable for things like confirming POA status or resolving conflicting documentation.