CCDS Healthcare Documentation 2

Question 1

Which of the following is considered a 'qualified provider' who may document diagnoses for ICD-10-CM coding purposes in the inpatient setting?

Accepted Answer

Attending physician or other qualified healthcare practitioner legally accountable for the patient's care

Answer

Per ICD-10-CM guidelines, diagnoses must be documented by the attending physician or other qualified healthcare practitioners who are legally accountable for establishing diagnoses in the inpatient setting.

Question 2

A discharge summary that conflicts with the body of the medical record should be handled in which of the following ways?

Accepted Answer

Query the physician to resolve the discrepancy before finalizing the coded record

Answer

When the discharge summary contradicts information in the body of the record, the physician should be queried to clarify and reconcile the conflict before coding.

Question 3

Which of the following documentation elements is REQUIRED by CMS Conditions of Participation for all inpatient medical records?

Accepted Answer

Authenticated history and physical completed within 24 hours of admission or prior to surgery

Answer

CMS Conditions of Participation require that a history and physical examination be completed and authenticated within 24 hours of admission or before any surgery.

Question 4

A physician uses the term 'urosepsis' in documentation. How should a CDI specialist respond?

Accepted Answer

Query the physician to clarify whether a UTI, sepsis due to UTI, or another condition is intended

Answer

The term 'urosepsis' is not a codeable ICD-10-CM term and has been used inconsistently to mean anything from a UTI to sepsis due to UTI. The CDI specialist must query the physician to clarify the intended clinical meaning before coding.

Question 5

Under HIPAA, which role has the authority to release a patient's medical records to a CDI specialist for documentation review?

Accepted Answer

The CDI specialist has inherent access as a member of the healthcare operations team

Answer

HIPAA permits covered entities to use patient health information for treatment, payment, and healthcare operations without patient authorization. CDI activities fall under healthcare operations.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Healthcare Documentation 2