CDIP Practice Exam 2

A review contractor sends a denial for the following: Attending physician states on history and physical likely pneumonitis and or bronchitis with failed outpatient treatment. The patient had a cough, green sputum, and fever of 101.3 on admission. The patient was started on IV antibiotics in broad coverage, Levaquin, Zosyn, and Vancomycin with 02 and IV steroids. Patient had a history of lung cancer with metastasis to the brain in remission, status post treatment. Discharge summary restates findings on chest angiogram that pneumonia could not be excluded. The principal diagnosis was changed to bronchitis. Based on the above information, which diagnosis should most likely be principal? a.Pneumonia b.Bronchitis c.Secondary neoplasm of the brain d.Lung cancer

a Based on the clinical findings of cough, green sputum, and fever with IV antibiotic coverage, pneumonia should be the principal diagnosis. Section II. Selection of Principal Diagnosis - The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care." Two or more diagnoses that equally meet the definition for principal diagnosis In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first (CMS 2016b; Section II).

All documentation entered in the medical record relating to the patient's diagnosis and treatment are considered this type of data: a.Clinical b.Identification c.Secondary d.Financial

a Basic clinical data, such as the type of surgery or reason for the visit, is collected and recorded during the intake process. From this, the treating or admitting physician can provide the patient's preliminary diagnosis and the reason the patient is seeking treatment. Accurate clinical data collection is important because it becomes the basis of care plans and helps determine medical necessity (Shaw and Carter 2014; Fahrenholz and Russo 2013, 77).

Due to the compliance concerns surrounding the possible leading queries, CMS has engaged which organization to assist in record review of certain diagnosis-related groups (DRGs) and documentation concerns? a.QIO b.PEPPER c.ONC d.Q-Net

a CMS has engaged the QIOs to assist in record review of certain diagnosis-related groups (DRGs) and documentation concerns (Hess 2015, 178).

Mr. Blanks is an 86-year-old male complaining of severe abdominal pain and diarrhea. The patient has recently presented with jaundice, white stools, swollen gallbladder, and hyperglycemic and hypoglycemic episodes. Colonoscopy, EGD, with abdominal ultrasound was performed with initial diagnosis of stomach and pancreatic malignant neoplasm. The patient underwent gastric resection with pancreactomy. The CDI may want to query for: a.Which is the primary neoplasm b.Type of neoplasm c.Cause of the jaundice d.Nothing; no query is warranted

a For neoplasms it is important to determine the site of the primary neoplasm and the site of metastasis. Query should be performed when information within the health record is unclear (AHIMA. 2013b: 50-53., 1).

A 45 year-old female had a necrotic cellulitis with ulcer of her lower limb. The surgeon performed deep debridement of the area with scalpel and pulsatile irrigation. Additional information needed for accurate code assignment may be needed. Which of the following best describes the most appropriate areas that should be queried? a.Excisional or nonexcisional; location of the wound; depth or type of necrosis; cause of the condition, if known; stage of the ulcer; present on admission indicator b.Excisional or nonexcisional; depth or type of necrosis; cause of the condition, if known; stage of the ulcer; present on admission indicator c.Excisional or nonexcisional, location of the wound, depth/type of necrosis, present on admission indicator d.No query needed

a For the proper assignment of cellulitis, ulcers, and debridement utilize Coding Clinic advice and ICD-10-PCS Guidelines. Documentation required by the physician/surgeon should include determination of excisional/nonexcisional removal of tissue, the most specific location of the wound, depth/type of necrosis such as muscle or bone, cause of the condition if known; i.e., diabetic, atherosclerotic, stage of the ulcer (I-IV), present on admission indicator determination (AHIMA 2015a).

A lithotripsy was performed as an outpatient for kidney stones. This is considered to be which root operation? a.Fragmentation b.Destruction c.Removal d.Extirpation

a Fragmentation. The solid matter may be an abnormal byproduct of a biological function or a foreign body. Physical force (e.g., manual, ultrasonic) applied directly or indirectly through intervening body parts is used to break the solid matter into pieces. The pieces of solid matter are not taken out, but are eliminated or absorbed through normal biological functions. Examples are Extracorporeal Shockwave lithotripsy, transurethral lithotripsy (Zeisset 2013, 41).

The practice of undercoding can affect a hospital's MS-DRG case mix in which of the following ways? a.It makes it lower than warranted by the actual service or resource intensity of the facility b.It makes it higher than warranted by the actual service or resource intensity of the facility c.It does not affect the hospital's MS-DRG case mix d.Coding has nothing to do with a hospital's MS-DRG case mix

a Medicare severity diagnosis-related group (MS-DRG) sets exist where the listings of diagnoses used to drive the grouping are the same but the presence or absence of a complication or comorbidity (CC) diagnosis or major complication or comorbidity (MCC) diagnosis assigns the case to a higher or lower MS-DRG. MS-DRG sets may contain two or three MS-DRGs. These MS-DRG relationships and sets pose a compliance concern because the medical record documentation used to support the coding of principal diagnosis, complications, and comorbidities may not always be clear or used appropriately by the coder (such as undercoding). Therefore, inaccurate coding can lead to incorrect MS-DRG assignment and thus inappropriate reimbursement and can affect a hospital's case mix (Casto and Forrestal 2013, 46).

A new CDS performed her daily reviews and utilized a discharge summary performed by the resident. During reconciliation of reviews, it was noted that the attending physician refused to sign the discharge summary and dictated an addendum. The CDS received a note from the department manager which stated _______ is responsible for the content of the record as the primary physician a.Attending physician b.Head nurse c.Consulting physician d.Admitting nurse

a The physician principally responsible for the patient's hospital care generally dictates the discharge summary. However, a resident, physician assistant, or nurse practitioner who is being supervised by the attending physician may complete this task. Regardless of who documents it, the attending physician is responsible for the content and quality of the summary and must date and sign it (Shaw and Carter 2014; Fahrenholz and Russo 2013, 284).

When an effective leader provides employees with information, responsibility, authority, and trust, this is called: a.Empowerment b.Promotion c.Vision d.Delegation

a The trend in modern organizations is to develop each employee's leadership potential to its full capacity. This allows the employees to exercise the empowerment they are given, demonstrate their value to the organization, and perhaps participate in leadership succession in the organization (Shaw and Carter 2014; LaTour et al. 2013, 750).

This type of malnutrition is rarely seen in the US and was a recent OIG target as an inappropriate diagnosis: a.Septic malnutrition b.Kwashikor malnutrition c.Pernicious malnutrition d.There have been no targets surrounding the coding of malnutrition

b Kwashikor malnutrition is rarely seen in the US and has been an OIG target area (AHIMA 2015a, 19).

A patient presents with a myocardial infarction (MI) and intervention was carried out. It was noted the patient does have coronary artery disease (CAD). The consulting physician has stated to staff the CAD should be sequenced first. What should be the principal diagnosis? a.CAD b.MI c.Chest pain d.Ill-defined condition

b No, the consultant's advice is not correct. Sequence the AMI as the principal diagnosis since it is the acute condition and the reason for the admission. You should continue to follow correct coding and reporting practices and report the AMI as the principal diagnosis (AHA Third Quarter 2009, 9-10. AHA, First Quarter 2012, 7).

If a patient has a chronic conditions with ongoing or long-term therapy but has presented to the hospital for another acute condition. These chronic conditions: a.Should be reported when they present to their office visit b.Cannot be reported c.Can be reported d.Are irrelevant diagnoses

c Based on Official Coding Guidelines for Coding and Reporting: For reporting purposes the definition for 'Other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring: Clinical evaluation; or Therapeutic treatment; or Diagnostic procedures; or Extended length of hospital stay; or Increased nursing care and/or monitoring (AHA Second Quarter 2000, 20-21; CMS 2016b, Section III).

Data that have been grouped into meaningful categories according to a classification system are referred to as ________ data. a.Research b.Reference c.Coded d.Demographic

c Coded data is data that is translated into standard nomenclature of classification so that it may be aggregated, analyzed, and compared (Shaw and Carter 2014; LaTour et al. 2013, 903).

If the physician does not document the diagnosis, the coding professional cannot assume the patient has a diagnosis based solely on a.An abnormal lab finding b.Abnormal pathology reports c.Both A and B d.None of the above

c The coder cannot assume diagnoses on abnormal findings such as lab reports. Abnormal findings (laboratory, X-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the diagnosis should be added (AHA 1990, 15).

The fiscal year 2016 Acute Inpatient Prospective Payment System Final Rule Tables can be used by the CDI specialist to determine the weight and estimated ___________ of each MD-DRG a.Case mix b.Formula c.Quality d.Payment

d The DRG tables for each fiscal year are located at www.cms.gov The tables provides weights of each DRG and can be utilized to calculate basic payment data (Hess 2015, 49).

The American Society for Testing and Materials (ASTM) Standard E2457-07, Standard Terminology for Healthcare Informatics is a helpful resource for a.evaluating the quality of a clinical terminology b.CDI improvement projects c.data integrity initiatives d.none of the above; it is irrelevant to CDI

a "HIM professionals should use all of their system analysis and data management skills when evaluating the appropriateness of a clinical terminology for a particular function or need. A helpful reference for evaluating the quality of a clinical terminology is the American Society for Testing and Materials (ASTM) Standard E2457-07, Standard Terminology for Healthcare Informatics" (Palkie 2013, 405)

Right Hospital has developed a tool to capture CDI performance and monitor the CDI team activities. This tracking and trending tool is called a: a.Dashboard b.Report c.Graphs d.Spreadsheet

a A dashboard can be utilized to show key CDI metrics to all key members in the process for program success (AHIMA 2014a, 7).

An abnormal finding (laboratory, x-ray, pathologic, and other diagnostic results) is not coded and reported unless the provider indicates its: a.Clinical significance. b.Clinical values. c.Impact on patient care. d.Impact on patient outcome.

a Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added (CMS 2016).

The financial statement that presents a record of operations by showing revenue and expenses over a period of time is called the: a.Income statement b.Balance sheet c.Statement of cash flows d.Statement of retained earnings

a An income statement summarizes the organization's revenue and expense transactions during the fiscal year. The income statement can be prepared at any point in time and reflects results up to that point (Shaw and Carter 2014; LaTour et al. 2013, 777).

Erin is the HIM director at Anywhere Hospital. She is teaching a class to clinicians about proper documentation in the health record. Which of the following would she not instruct them to do? a.Obliterate errors b.Leave existing entries intact c.Label late entries as being late d.Ensure the legal signature of an individual making a correction accompanies the correction

a Any corrections to the record must be entered properly. In paper records, the provider should draw a single line through the error, add a note explaining the error, initial and date the error with the date it was discovered, and enter the correct information in chronological order. For electronic entries, a procedure should be followed that explains how to correct errors and enter addenda to the health record (Shaw and Carter 2014; LaTour et al. 2013, 264).

For PSI (Patient Safety Indicators) 11: Postoperative respiratory failure documentation may require query to improve documentation for: a.The reason for prolonged intubation when noted. b.Disregarding this PSI c.Intubation noted to exist anytime following surgery. d.None of the above

a As published by the AHRQ (Agency on Healthcare Research and Quality) toolkit, PSI 11: Postoperative respiratory failure Avoid using coding for intubation as it is an expected part of a procedure. Improve documentation of the reasons for reintubation or prolonged ventilation. Three clinical issues that were identified during the project potentially warrant further attention. There were two cases of oversedation leading to respiratory complications; some patients likely could have been extubated earlier, which would not have counted as respiratory failure; and several cases had massive blood loss, which seemed to precipitate postoperative respiratory issues (AHRQ 2015).

A patient was admitted with HIV and pneumocystic carini. The patient should have a principal diagnosis in ICD-10 of: a.AIDS b.Asymptomatic HIV c.Pneumonia d.Not enough information

a If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, Human immunodeficiency virus [HIV] disease followed by additional diagnosis codes for all reported HIV-related conditions (ICD-10-CM Official Guidelines for Coding and Reporting 2016a, 17).

A CDI program should have ongoing monitoring to ensure CDI activities are being performed compliantly and accurately. This process is called. a.Quality Assurance Tool/Program b.CDI Monitoring Tool/Program c.CDI Checks and Balances Tool/Program d.This process is not required as long as knowledgeable staff is utilized

a It is important to implement a Quality Assurance Audit Tool/Program to perform review of CDI functions and activities. It is important for a facility to have checks and balances in place to ensure the highest level of integrity as CDI programs mature. External audits will be scrutinizing health records closely for documentation, including those by RAC contractors. When developing a CDI program, a strong QA process can aid in achieving a successful and compliant program (AHIMA 2014a, 6).

What coding system is published by the AMA and represents medical services and procedures performed by physicians and other healthcare providers. a.CPT b.ICD-10-PCS c.ICD-10 CM d.POA

a Level I of HCPCS is composed of the CPT codes as published by the AMA and represents medical services and procedures performed by physicians and other healthcare providers. The Level I (CPT) codes (other than the Category II and III codes) are five-digit numeric codes (Palkie 2013, 394).

A database containing information and files submitted by fiscal intermediaries that is used by the Office of the Inspector General to identify suspicious billing and charge practices a.MEDPAR Medicare Provider Analysis and Review (MEDPAR) database system b.ORYX c.MS-DRG d.PQRS

a MEDPAR Medicare Provider Analysis and Review (MEDPAR) data- base contains information and files submitted by Medicare administrative contractors and utilized by OIG to identify suspicious billing and charge practices (AHIMA 2014a, 24).

In assessing the quality of care given to patient with diabetes mellitus, the CQI group collects data regarding blood sugar levels on admission and on discharge. The data is called a(n): a.Indicator b.Measurement c.Assessment d.Outcome

a Medicare severity diagnosis-related group (MS-DRG) sets exist where the listings of diagnoses used to drive the grouping are the same but the presence or absence of a complication or comorbidity (CC) diagnosis or major complication or comorbidity (MCC) diagnosis assigns the case to a higher or lower MS-DRG. MS-DRG sets may contain two or three MS-DRGs. These MS-DRG relationships and sets pose a compliance concern because the medical record documentation used to support the coding of principal diagnosis, complications, and comorbidities may not always be clear or used appropriately by the coder (such as undercoding). Therefore, inaccurate coding can lead to incorrect MS-DRG assignment and thus inappropriate reimbursement and can affect a hospital's case mix (Casto and Forrestal 2013, 46).

A ________ assists in educating medical staff members on documentation needed for accurate billing. a.Physician champion b.Compliance officer c.Chargemaster coordinator d.Data monitor

a Physician champion. The health information manager must continuously promote complete, accurate, and timely documentation to ensure appropriate coding, billing, and reimbursement. This requires a close working relationship with the medical staff, perhaps through the use of a physician champion. Physician champions assist in educating medical staff members on documentation needed for accurate billing. The medical staff is more likely to listen to a peer than to a facility employee, especially when the topic is documentation needed to ensure appropriate reimbursement (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 381).

Within 2 hours following surgery, a 68 year-old female began to develop noisy breathing, fever, tachypnea, chest discomfort, and cough. Chest x-ray was performed which showed increased interstitial markings, lobar consolidation, and atelectasis. The physician documented pneumonia; concern for aspiration. The patient was started on Cefepime. The CDS would most likely query for: a.Postoperative aspiration pneumonia b.Respiratory failure c.Bacterial pneumonia d.No query needed

a Postprocedural aspiration pneumonia was developed to uniquely capture this condition and distinguish it from other respiratory complications Query as appropriate utilizing appropriate query format. (AHIMA 2013b).

A clinical documentation specialist (CDS) is employed at ABC hospital. She has been consistently having conversations with the hospitalists on what they should document on every patient that presents with fever and receives antibiotics. As director, you should: a.Review the AHIMA Query Brief with the CDS b.Review the escalation policy with the CDS c.Ensure all staff have the same proactive approach d.No attention to this area is needed

a Review the AHIMA Query Brief with the CDS. Verbal queries should contain the same clinical indicators and follow the same format as written queries to ensure compliance and consistency in policy and process. Documentation of the verbal query may be condensed to reflect the stated information, but should identify the clinical indicators that support the query as well as the actual question posed to the practitioner. Verbal queries should be documented at the time of the discussion or immediately following (AHIMA 2013a, 50-53).

The American Hospital Association (AHA), the American Health Information Management Association (AHIMA), Center for Medicare and Medicaid Services (CMS), and National Center for Healthcare Statistics (NCHS) are all a.Cooperating parties b.Governing bodies c.Coding associations d.Work independently to develop coding guidelines

a The American Hospital Association (AHA), the American Health Information Management Association (AHIMA), Center for Medicare and Medicaid Services (CMS), and National Center for Health Statistics (NCHS) are all cooperating parties that developed and approved ICD-10-CM/PCS (ICD-10-CM Official Guidelines for Coding and Reporting 2016a, 1).

The appeal coordinator received a denial that stated: On presentation, patient had hemoglobin of 8.8 with blood in stool noted in physician office...patient sent as direct admission straight to hospital. The physician notes 11/05/14 states GI bleeding will consider transfusion 11/06/14. Note also states melenic stools and states hemoccult positive. Endoscopy report states - Acute Posthemorrhagic Anemia with iron deficiency anemia due to blood loss. "Multiple small angioectasias without bleeding were found in the second part of the duodenum. Red blood was found on the greater curvature of the stomach. Multiple small angioectasias with stigmata of recent bleeding were found in the gastric body. No active bleeding or clear which angioectasia are bleeding source." Multiple recently bleeding angioectasias in the stomach. Hemoglobin and hematocrit low on admission and decreased following admission at 8.8 to 8.2 and 27.8 to 26.8 respectively. Patient transfused packed RBCs on 11/5/14. Based on the above information , the review contractor: a.Denied the DRG inappropriately b.Was correct to deny the DRG, no query needed c.Should not have denied the DRG d.Was correct to deny, query needed

a The assignment of the code is appropriate. If the physician clearly documents the anemia is due to acute blood loss, code D62 Acute posthemorrhagic anemia should be assigned. Anemia due to chronic blood loss is coded to D50.0 Secondary to blood loss (chronic). The physician should always be queried if there is a lack of sufficient documentation. Never assume cause and effect relationship (AHA Fourth Quarter 1993, 34; ICD-10-CM Official Guidelines 2016b).

Based on the diagnosis of gross hematuria, signs and symptoms of irregular heartbeat, malaise, and hemoglobin of 10.8 with transfusion, query for anemia due to blood loss may be______: a.Appropriate b.Inappropriate

a The generation of a query should be considered when the health record documentation: •Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent •Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis •Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure •Provides a diagnosis without underlying clinical validation •Is unclear for present on admission indicator assignment

A patient was admitted to an acute care facility with a temperature of 102 and atrial fibrillation. The chest x-ray reveals pneumonia with subsequent documentation by the physician of pneumonia in the progress notes and discharge summary. The patient was treated with oral antiarrhythmia medications and IV antibiotics. What is the principal diagnosis? a.Pneumonia b.Arrhythmia c.Atrial fibrillation d.Both a and c

a The patient presented with clinical signs of Pneumonia along with treatment. The atrial fibrillation was a chronic condition that can be reported additionally (CMS 2016b).

If a patient is given Levophed, the patient is most likely being treated for which of the following diagnoses? a.Shock b.Infection c.Hemorrhage d.Infarction

a This is a treatment for shock (septic and cardiogenic). (Society of Critical Care Medicine 2013)

Which of the following is the best reason for team building? a.To quickly move from acquaintanceship to a strong team b.To identify a leader c.To help employees develop a common purpose d.To ensure that the leader's situation is favorable

a To quickly move from acquaintanceship to a strong team. One thing that binds team members together is having a common purpose. The purpose for an ongoing work team, for example, might be to ensure cross-training, improve procedures, and monitor quality and productivity. A common purpose is necessary in order to achieve team building (Shaw and Carter 2014; LaTour et al. 2013, 753).

Mildred Smith was admitted to a nursing facility with the following information: "Patient is being admitted for Organic Brain Syndrome." Underneath the diagnosis, her medical information was listed along with a summary of the care already provided. This information is documented on the: a.Transfer record b.Release of information form c.Patient's rights acknowledgment form d.Admitting physical evaluation record

a Transfer records are created whenever a patient is transferred from one facility to another. The transfer record contains a summary of the care provided in the facility from which the patient is being transferred as well as the reason for transfer. Transfer records are important to the continuum of care because they document communication between caregivers in multiple settings (Shaw and Carter 2014; Fahrenholz and Russo 2013, 225).

During an outpatient procedure for removal of a bladder cyst, the urologist accidentally tore the urethral sphincter requiring an observation stay. This should be assigned as the principal diagnosis: a.The reason for the outpatient surgery b.The reason for admission c.Either the reason for the outpatient surgery or the reason for admission d.None of the above

a When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses (ICD-10-CM Official Guidelines for Coding and Reporting 2016a, 103).

Mrs. Spade was admitted with pain, redness, and exudate noted of the right knee. The patient had a replacement last week of the right knee. The patient was taken back to the OR and was noted to have loosening noted on brief operative note. Replacement was performed. The physician documented osteoarthritis of the knee. The diagnosis query that could better reflect the severity of illness and resources utilized for this patient could be a.Mechanical complication of internal fixation device b.Septic knee c.Traumatic knee injury d.Fracture of knee joint

a With findings of pain, redness, and exudate with prior replacement last week of the right knee with loosening noted, query could be warranted for complication of an internal fixation device to validate loosening from bone. •Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent •Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis •Includes clinical indicators, diagnostic evaluation, or treatment not related to a specific condition or procedure •Provides a diagnosis without underlying clinical validation •Is unclear for present on admission indicator assignment (AHIMA 2013a, 1)

The coding director has some concerns related to the capture of encephalopathy. She plans to take a closer look of coding, CDI, and code assignment. The director is performing a a.A self-audit b.A self-review c.A risk assessment d.Compliance review

a Within a given health care practice or business, providers perform a self-audit. This is an audit, examination, review, or other inspection performed both by and facility. Self-audits generally focus on assessing, correcting, and maintaining controls to promote compliance with applicable laws, rules, and regulations (CMS 2016d).

The CDI manager has identified a trend with receiving inappropriate clinical validation denials from the CMS RAC for their region. It has been stated a written letter can be sent to this contractor prior to appeal. This is called a ___________ a.Rebuttal. b.Discussion. c.Level I. d.Peer to peer session

b "The discussion period offers the opportunity for the provider to provide additional information to the RAC to indicate why recoupment should not be initiated. It also offers the opportunity for the RAC to explain the rationale for the overpayment decision. After reviewing the additional documentation submitted the RAC could decide to reverse their decision" (CMS 2015c).

In project management, what is a work breakdown structure? a.A list of the project deliverables b.A hierarchical list of the project tasks c.A document that defines team roles and responsibilities d.A list of project scope changes

b A project plan starts with a work breakdown structure (WBS), or task list. The WBS is a hierarchical list of steps needed to complete the project. This structure provides levels that are similar to the concept of a book outline. Each level drills down to more detail. The lowest level is the task level, which is the level to which resources are assigned and work effort estimates are made (Shaw and Carter 2014; LaTouretal. 2013,842).

This is a communication tool used to clarify documentation in the health record for accurate code assignment. a.Attestation b.Query c.Health record inquiry d.Additional documentation request

b A query is a communication tool used to clarify documentation in the health record for accurate code assignment. This tool is usually generated by coding and CDI staff (AHIMA 2013b, 1).

Research on emotional intelligence shows that: a.Emotions do not have much of a role in the workplace. b.A combination of feelings and rationality make managers more successful. c.It is a clearly defined measure that can be precisely assessed. d.Effective managers and successful managers are the same.

b Advocates of emotional intelligence believe that awareness and use of feelings complements rational intelligence and experience, and it is the combination of these that is the key to success (Shaw and Carter 2014; LaTour et al. 2013, 693).

Providers should maintain queries: a.Indefinitely b.Based on their facility policy c.Never d.Until the patient expires

b Based on your facility policy. Retention of the query varies by healthcare organization. First, an organization must determine if the query will be part of the health record. If the query is not part of the health record, then the organization must decide if the query is kept as part of the business record or only the outcome of the query is maintained in a database (AHIMA 2013b).

A review contractor sends a denial for the following: Attending physician states on history and physical likely pneumonitis and or bronchitis with failed outpatient treatment. The patient had a cough, green sputum, and fever of 101.3 on admission. The patient was started on IV antibiotics in broad coverage, Levaquin, Zosyn, and Vancomycin with 02 and IV steroids. Patient had a history of lung cancer with metastasis to the brain in remission, status post treatment. Discharge summary restates findings on chest angiogram that pneumonia could not be excluded. The principal diagnosis was changed to bronchitis. What type of denial is this? a.DRG b.DRG with clinical validation c.Medical necessity d.Level of care

b CMS has approved DRG reviews with clinical validation. This type of review involves ensuring that the diagnosis is documented by the physician and clinically supported. Contractors often utilize this review method for DRG denials (AHIMA 2014b)

A 40-year-old female presented with a malignancy of the right ovary diagnoses 1 week ago. The patient also exhibited symptoms of confusion, headache, difficulty walking, and blurred vision. Following extensive workup, it was determined the patient had a malignancy of the cerebrum of the brain. The CDS should query to determine: a.Primary site. b.Metastasis from and to. c.Secondary site. d.POA indicator for the cerebrum malignancy.

b Chapter 2 of the ICD-10-CM contains the codes for most benign and all malignant neoplasms. Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. If malignant, any secondary (metastatic) sites should also be determined (CMS 2016).

An organization should have a query policy and procedure to: a.Learn how to write queries. b.Outline the physician's responsibility in responding to queries. c.Assist in the CDS hiring process. d.Outline the components of the medical record.

b Every organization should develop a query policy and procedure that is specific to its organization and that addresses •When to ask queries •Who asks queries and to whom •The hospital's responsibility in supporting the query process •The physician's responsibility in responding to queries •Acceptable ways to respond to queries

These notes have been expanded at the beginning of each chapter to clarify the hierarchy of the chapters: a.Blocks b.Exclusion notes c.Titles d.Inclusion notes

b Exclusion notes have been expanded at the beginning of each chapter to clarify the hierarchy of the chapters. As explained previously, the special-group chapters have priority over the organ or system chapters. In addition, the chapters for pregnancy, childbirth and the puerperium (XV) and certain conditions originating in the perinatal period (XVI) take precedence over the other special-group chapter (Zeisset 2013, 21).

Patient is diagnosed with congestive heart failure. The physician states this is CHF with diastolic dysfunction due to hypertension. That diagnosis should be listed as principal: a.Hypertension b.Hypertensive heart disease with heart failure c.Congestive heart failure d.Either

b Hypertensive heart disease with heart failure. If a patient has hypertensive heart disease with congestive heart failure due to hypertension, it is appropriate to assign a code for the hypertensive heart disease with heart failure as the principal diagnosis (AHA Fourth Quarter 2002, 49-52).

If a code does not agree with a code corresponding with the Medicare Code Edit table of acceptable codes, it is considered a.Duplicate b.Invalid c.Conflicting d.Unacceptable

b If a code does not agree with a code corresponding with the Medicare Code Edit table of acceptable codes it is considered invalid and should be rejected (CMS Medicare Code Editor 2015).

Patient is admitted with acute congestive heart failure treated with diuretics and education. The patient also had atrial fibrillation which the physician stated as the cause of the heart failure. Which condition should be assigned as principal? a.Coding rules state query should be performed b.The condition documented as causing the admission c.Either diagnosis d.Neither

b If both conditions are present on admission and meet the definition of principal diagnosis, either condition may be sequenced as principal diagnosis. The Official Guidelines for Coding and Reporting, Section II, B., state "When there are two or more interrelated conditions (such as diseases in the same ICD-9-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise." If, however, one of the conditions is clearly documented as causing the admission, then that condition should be designated as the principal diagnosis. See also Coding Clinic, Second Quarter 1990, page 4, for additional examples (AHA First Quarter 2012, 7).

If observation status is ordered, the facility cannot decide that the stay should be IP (inpatient) and bill IP unless: a.The CDS updates the admission order b.There is a subsequent order to admit the patient by the physician responsible for the patient's care at the hospital. c.Inpatient cannot be ordered d.Unless a condition code 44 is performed

b Inpatient services cannot be billed without an IP order by the physician responsible for the patient's care at the hospital (CMS 1210).

The advantage of using internal change agents over external change agents is that the former can usually: a.Be accepted by employees as being more objective. b.Provide a more detailed understanding of healthcare entity's history and issues. c.More easily challenge healthcare entity norms and culture. d.Benchmark the healthcare entity against others.

b Internal change agents have the clear advantage of being familiar with the organization, its history, subtle dynamics, secrets, and resources. Such people are often well respected, securely positioned, and have the strong interpersonal relationships to foster change. There is an advantage to recognizing the internal expertise of employees, maintaining confidentiality of the process, and using people who are invested in the success of the outcome (Shaw and Carter 2014; LaTour et al. 2013, 708).

The new CDI manager has decided the query will become a part of the health record stating this is required. a.The query has to be a part of the health record b.An organization must determine if the query will be part of the health record c.The query should be disposed of after completion d.All queries should be verbal

b It is the decision of an organization of how to maintain queries and whether to include them as part of the health record. . Retention of the query varies by healthcare organization. First, an organization must determine if the query will be part of the health record. If the query is not part of the health record, then the organization must decide if the query is kept as part of the business record or only the outcome of the query is maintained in a database (AHIMA 2013b).

The Clinical Documentation Program at ABCD Medical Center has made significant strides to improve their physician engagement at their facility and had reduced their physician response to 98 percent over a one year period. Their CMO has recommended the team share their success by: a.Not put too much emphasis on the initiative b.Publish this in a research journal for physician education and facility awareness c.Make adjustments to their CDI process as 80 percent compliance is the facility goal d.None of the above

b Performing research around the CDI initiatives and writing publications can be beneficial for the CDI program and the facility. This co-development can also foster physician understanding in the process and individual documentation accountability. To communicate effectively, managers must pay just as much attention to how their message is received and interpreted as they do to its content. In order to enhance the accuracy and acceptance of communication, the communicator needs to monitor others' nonverbal behaviors for cues that they are following or confused. Passive listening and distracted parties would not enhance effective communication (Shaw and Carter 2014; Hess 2015, 231).

The coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution to handle this documentation issue? a.Have coders continue to query the attending physician for this documentation. b.Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines. c.Do nothing because coding compliance guidelines do not allow any action. d.Place all offending physicians on suspension if the documentation issues continue.

b Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines. The quality of the documentation entered in the health record by providers can have major impacts on the ability of coding staff to perform their clinical analyses and assign accurate codes. In this situation, the best solution would be to educate the entire medical staff on their roles in the clinical documentation improvement process. Explaining to them the documentation guidelines and what documentation is needed in the record to support the more accurate coding of diabetes and its manifestations will reduce the need for coders to continue to query for this clarification (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 285).

APR-DRGs have levels (subclasses) of severity entitled: a.Excessive, Major, Moderate, Minor b.Extreme, Major, Moderate, Minor c.Extreme, Major, Moderate, Minimal d.Excessive, Major

b The APR-DRG system is distributed into levels (subclasses) similar to MS-DRGs. These levels are entitled Extreme, Major, Moderate, Minor (Hess 2015, 48)

A 42-year-old female underwent an emergent total hysterectomy due to tear of the uterus due to grapefruit-sized fibroid. The patient was transfused 3 units of packed red blood cells for anemia with a hemoglobin of 8.2. In this specific scenario, which query is appropriate: a.The CDI must query the cause of the fibroid b.Patient noted to have tear of the uterus with hemoglobin 8.2 and transfusion of 3 units RBCs. Is the patient's anemia due to blood loss? Yes or No c.Query not warranted d.The CDI must ask an open ended query

b The CDI can perform a Yes and No query to determine if the anemia is due to blood loss (AHIMA 2013b, 50-53)

The Glasgow Coma Scale provides an objective assessment of a patient's level of consciousness for specific dates and times. If a patient's scores are outside of the normal range and no corresponding neurological diagnosis is present, the CDS should: a.Not be concerned with this clinical finding. b.Initiate a query to clarify the report findings. c.Query for altered mental status. d.Assign a code for abnormal findings on examination.

b The Glasgow Coma Scale are often found within the Neurological Flowsheet or other Neuro Assessment documents, provides an objective assessment of a patient's level of consciousness for specific dates and times. Where scores are beyond the normal ranges and no corresponding neurological diagnosis is present, the coder should query the physician (Hess 2015, 19).

Strategic thinkers exhibit which of the following skills? a.Discomfort with uncertainty and risk b.The ability to gain a powerful core of healthcare entity supporters and customers c.Flexibility but lacking creativity d.An ability to implement the vision and plan and be uncomfortable with change

b The ability to gain a powerful core of healthcare entity supporters and customers. Strategic thinking is a way of introducing innovation into decision making and engaging others in the process of change. The skills that distinguish a strategic thinker include the ability to plan and strategize, flexibility and creativity, comfort with uncertainty and risk, a sense of urgency and vision of how to move change forward positively, being able to gain a powerful core of organizational supporters and customers, and the capability to communicate the vision and plans (Shaw and Carter 2014; LaTour et al. 2013,868).

The codes for postoperative complications have been expanded and a distinction made between intraoperative complications and what? a.Other postop complications b.Postprocedural disorders c.Complications of trauma d.Intraoperative lacerations

b The codes for postoperative complications have been expanded and a distinction made between intraoperative complications and postprocedural disorders (Zeisset 2013, 35).

The primary responsibility of a coder is to: a.Ensure timely processing of coded data b.Ensure quality of coded data c.Avoid claims rejections by third-party payers d.Ensure maximum reimbursement for the facility

b The coding professional's first responsibility is to ensure the accuracy of coded data. To this end, AHIMA has established a code of professional ethics by which coders must abide (LaTour et al. 2013, 442).

A patient presents with delirium. The patient has a strong smell of alcohol, and family member states the patient has been drinking alcohol all day. Alcohol levels are reported to be outside of the normal limits. The physician documents acute alcohol intoxication with delirium. Based on this, is it appropriate to query for metabolic encephalopathy? a.Yes, a query is warranted for metabolic encephalopathy. b.No, a query is not warranted for metabolic encephalopathy. c.Assign the diagnosis of metabolic encephalopathy without query. d.Query for CVA.

b The patient has acute alcohol intoxication with delirium. "Metabolic encephalopathy is always due to an underlying cause. There are many causes of metabolic encephalopathy, such as brain tumors, brain metastasis, cerebral infarction or hemorrhage, cerebral ischemia, uremia, poisoning, systemic infection, etc. Metabolic encephalopathy is also a common finding in 12-33% of patients suffering from multiple organ failure. The development of metabolic encephalopathy may be the first manifestation of a critical systemic illness and may be caused by various reasons—one of the most important being sepsis" (AHA Fourth Quarter 2003, 58-59).

Using the admission criteria provided, determine if the following patient meets severity of illness and intensity of service criteria for admission. Severity of IllnessIntensity of servicePersistent feverInpatient-approved surgery or procedure within 24 hours of admissionActive bleedingIntravenous medications or fluid replacementWound dehiscenceVital signs every 2 hours or more often John Smith presents to the emergency room at 1500 hours with a fever of 101 degrees F, which he has had for the last three days. He was discharged six days ago following a colon resection. X-rays show a bowel obstruction and the plan is for admission with inpatient surgery in the morning. a.The patient does not meet both severity of illness and intensity of service criteria. b.The patient does meet both severity of illness and intensity of service criteria. c.The patient meets intensity of service criteria but not severity of illness criteria. d.The patient meets severity of illness criteria but not intensity of service criteria.

b The patient meets severity of illness with the persistent fever and intensity of service with the inpatient-approved surgery scheduled within 24 hours of admission (Shaw and Carter 2014; Shaw and Elliott 2012, 113, 120)

A patient presents through the ED and was admitted with wheezing, peripheral edema, with a history of underlying ischemic heart disease and an ejection fraction of less than 45 percent. X-ray shows pulmonary edema with elevated BNP B-type Natriuretic Peptide). The patient was started with diuresis. The physician documents CHF, congestive heart failure. Based on the above, query should be performed for: a.Pulmonary congestion b.The type and location of the CHF c.No query is needed d.None of the above

b The physician documents CHF exhibiting acute phase of this chronic condition. A physician query is a question directed to a physician to obtain clarification of documentation in a patient's record when the current documentation does not meet one or more of the criteria for high-quality clinical documentation. Therefore, the patient's record must contain clinical evidence to support any questions (or queries) the CDI specialist asks the physician regarding documentation in that record (Hess 2015, 176).

A patient was admitted with chest pain with extension to the shoulder with weakness and severe headache. The patient has a history of migraines but the physician states the etiology of the headache since the patient also fell on the night prior to admission. The patient undergoes a CT scan of the head and a cardiac cath as the patient had troponins of 3.0 mg/mL. The principal procedure performed is the: a.CT scan of the head b.Cardiac catheterization c.Either can be listed as the principal procedure d.Neither can be listed as the principal procedure

b The principal procedure in this case the cardiac catheterization is the procedure that was performed for the definitive treatment (rather than the diagnosis) of the main condition or a complication of the condition (Shaw and Carter 2014; LaTour et al. 2013, 432, 940).

The CDS at ABC Hospital has had ongoing problems with disagreements between the recommended DRG and final DRG assigned by the coder. The coding manager has recommended a policy to expedite this process for final billing. This is called a a.Coding policy b.Escalation policy c.Final Billing policy d.Resolution policy

b To ensure a process is in place to resolve issues between, CDS, Coders, and Physicians, it is recommended an escalation policy is instituted (AHIMA 2013a).

CDI programs should have a measure of program effectiveness. These measures are called: a.Goals b.Thresholds c.Benchmarks d.Key performance indicators (KPIs)

b Tracking and presenting key performance indicators (KPI) to the governance committee and CDI task force keeps the program highly visible in the organization (Hess 2015, 213).

The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as: a.Unbundling b.Upcoding c.Medically unnecessary services d.Billing for services not provided

b Upcoding is the practice of using a code that results in a higher payment to the provider that actually reflects the service or item provided (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 372).

An effective CDI program should be able to capture what percentage of responses concurrently: e.0-25 percent f.25-50 percent g.70-75 percent h.100 percent

c "An effective program should be able to capture 70 to 75 percent of query responses concurrently" (AHIMA 2014a, 16).

Which graphic tool would be used to graph the number of deaths due to prostate cancer from 2005 through 2012? a.Frequency polygon b.Histogram c.Line graph d.Pie chart

c A line graph is used to display time trends. The x-axis shows the unit of time from left to right, and the y-axis measures the number of prostate cancer deaths (Shaw and Carter 2014; LaTour et al. 2013, 511-512).

The following conditions are considered _________: ABO incompatibility, falls and trauma, air embolism, stage III and IV ulcers a.PSIs (Patient safety indicators) b.POAs (Present on admission indicators) c.HACs (Hospital acquired conditions) d.Acute and chronic conditions

c As part of the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2009 Final Rule, CMS included 10 categories of conditions that were selected for as Hospital Acquired Conditions. Currently there are 14 categories which include Air Embolism, Blood Incompatibility, Stage III and IV Pressure Ulcers, and Falls and Trauma. See https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html for full listing (CMS 2013).

On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee with authorized access to patient records is printing far more records than the average user. In this case, what should the supervisor do? a.Reprimand the employee. b.Fire the employee. c.Determine what information was printed and why. d.Revoke the employee's access privileges.

c Audit trails are used to facilitate the determination of security violations and to identify areas for improvement. Their usefulness is enhanced when they include trigger flags for automatic, intensified review. In this case, the audit trail review should be used to begin an investigation into what exactly the employee printed and why (Shaw and Carter 2014; LaTour et al. 2013, 101).

An elevated BNP (B-type natriuretic peptide) noted on laboratory findings is a clinical indicator utilized in the diagnosis of: a.Diabetes b.Atrial fibrillation c.Congestive heart failure d.CVA

c BNP (B-type natriuretic peptide) has shown to be a strong indicator in the prognosis and risk stratification in CHF patients (Maisel 2002).

A technique for measuring healthcare entity performance across the four perspectives of customer, financial, internal processes, and learning and growth is called: a.Strategy map b.Process innovations c.Balanced scorecard methodology d.SWOT analysis

c Balanced scorecard methodology is a technique for measuring organization performance across the four perspectives of customer, financial, internal processes, and learning and growth (Shaw and Carter 2014; LaTour et al. 2013, 881).

Mr. Ace was seen in the outpatient clinic and treated with Z-Max for bronchitis. The patient presented to the ED with tachycardia, cough, fever, and green sputum. Chest x-ray was performed with left lower lobe infiltrate. The patient was admitted with bronchitis. Sputum cultures were obtained in the ED as it was discovered the patient never filled the Z-Max prescription. Sputum showed Staph and the patient was started on Vancomycin. The patient was discharged with a diagnosis of acute bronchitis. The diagnosis query that could better reflect the severity of illness and resources utilized for this patient and is clinically supported would be a.Acute or chronic bronchitis b.Sepsis c.Pneumonia d.Sepsis and pneumonia

c Based on failed outpatient treatment the clinical findings of tachycardia, cough, fever, and green-sputum, chest x-ray was performed with left lower lobe infiltrate, and positive sputum cultures, query could be warranted for pneumonia. •Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent •Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis •Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure •Provides a diagnosis without underlying clinical validation •Is unclear for present on admission indicator assignment

A successful CDI program must identify goals to ensure success of the program across the organization and clear understanding of program strategy. Identify a goal below that most accurately displays this. a.Train all CDI Staff in inpatient coding b.Ensure all physicians complete their training modules c.Identify and clarify missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures d.Complete five queries per day

c CDI programs are seen as the bridge between a host of professionals, such as physicians, case management, coding professions, quality management, and financial services. Any successful program operates by utilizing clearly defined goals and measurements. Some examples of CDI goals include: •Obtain clinical documentation that captures the patient severity of illness and risk of mortality •Identify and clarify missing, conflicting, or nonspecific physician documentation related to diagnoses and procedures •Support accurate diagnostic and procedural coding, MS-DRG assignment, leading to appropriate reimbursement •Promote health record completion during the patient's course of care, which promotes patient safety •Improve communication between physicians and other members of the healthcare team •Provide awareness and education •Improve documentation to reflect quality and outcome scores •Improve coders' clinical knowledge

This catheter is inserted into larger, deeper veins such as the subclavian, jugular, or femoral veins. The catheter is then advanced into the superior vena cava leading directly to the heart. a.Peripherally inserted central catheter (PICC) b.Vascular access device (VAD) c.Central venous catheter d.None of the above

c Central venous catheters are inserted into larger, deeper veins such as the subclavian, jugular, or femoral veins. The catheter is then advanced into the superior vena cava leading directly to the heart. Central venous catheters may be inserted by physicians, but are often inserted by other specially trained personnel such as physician assistants, nurse practitioners, or critical care nurses. Central venous catheterization is usually performed in the subclavian vein by a subclavicular approach. Another site is the internal jugular vein. The femoral vein is used infrequently because of concern over deep vein thrombosis (DVT) (AHA First Quarter 1996, 3-4).

These documents would be used for are used by clinicians and providers to identify abnormal temperature, blood pressure, pulse, respiration, oxygen levels, and other indicators. a.Nurses' graphic records b.Vital sign flowsheets c.Both A and B d.None of the above

c Clinicians and providers utilize various documents to identify abnormal temperature, blood pressure, pulse, respiration, oxygen levels, and other indicators. These documents are often called nurses' graphic records or vital sign flowsheets (Hess 2015, 43).

This system is currently being used in EHR systems as a clinical reference terminology to capture data for problem lists and patient assessments at the point of care. a.Problem-oriented record b.CPT c.SNOMED CT d.DSM-V

c EHR systems are utilizing SNO-MED CT as a clinical reference terminology to capture data for problem lists and patient assessments at the point of care. HHS recommended SNOMED CT as part of a core set of patient medical record information (PMRI) terminology in 2003 (Palkie 2013, 398).

According to Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed? a.Admission record b.Physician's order c.Report of history and physical examination d.Discharge summary

c Except in emergency situations, every surgical patient's chart must include a report of a complete history and physical conducted no more than seven days before the surgery is to be performed (Shaw and Carter 2014; Fahrenholz and Russo 2013, 238)

A CDI program should be governed by policies and procedures. These policies and procedures should be developed with the assistance of other departments affected by clinical documentation, including compliance, case management, and what other department? a.Information systems b.Process improvement c.Health Information Management (HIM) d.Finance

c HIM These policies and procedures should be developed with the assistance of other departments affected by clinical documentation, including compliance, case management, and HIM (AHIMA 2013b).

In 1990, 3M created which DRG system that several states use for Medicaid reimbursement and is also used by facilities to analyze some portion of the data for Medicare Quality Indicators. What is this system called? a.MS-DRGs b.AP-DRGs c.APR-DRGs d.CPT-DRGs

c In 1990, 3M created APR-DRGs, which several states use for Medicaid reimbursement. APR-DRGs are used by facilities to analyze some portion of the data for Medicare Quality Indicators (Hess 2015, 48)

The CDI manager at Star Hospital has been concerned about the hospital quality ratings over the past 2 years. She has been focused on educating physicians on documentation and working with CDS staff on hospital acquired conditions, MCC/CC capture. She may also want to educate regarding which area below to increase quality score: a.The principal diagnosis b.The principal procedure c.SOI d.None of the above

c It is beneficial for hospitals to monitor severity levels. It has been determined that better quality ratings if the majority of their inpatients are in higher severity group levels (Hess 2015, 197).

A patient was admitted with a CVA due to subarachnoid hemorrhage. On day two, it was noted the patient had an elevated BUN and creatinine 3 times the baseline with anuria. The physician documents acute kidney injury or failure. This diagnosis may warrant a.Query for acute renal failure b.Query for present on admission c.No query warranted d.Query for CVA

c No query warranted. There is no conflicting, unclear information. •Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent •Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis •Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure •Provides a diagnosis without underlying clinical validation •Is unclear for present on admission indicator assignment

After a 10-day admission, the physician dictates a discharge summary. The patient, an 86-year-old female, presented with CVA with bleed confirmed on MRI. The patient was noted to have some residual problems with movement on the right side and drawing of the face on the right side with some difficulty speaking. It was decided the patient would have a swallowing test performed on day 5 of admission prior to discharge due to concerns by speech therapy. Prior to evaluation and on the day of initial planned discharge, it was noted that the patient had a fever, dyspnea, tachypnea with some crackles and rales in the bases. Fever was 101.1 degrees with WBCs of 13,000, with no cultures, and consolidation on chest x-ray. Patient's final diagnosis is CVA with hemorrhage, chronic COPD, diabetes. Plan to see patient in the office in 7 days from home. Based on the information above, it would be appropriate to query for: a.Gram negative pneumonia b.Nothing; no query is warranted c.Aspiration pneumonia d.CVA

c Pneumonia Documentation Suggestions: Describe clinical signs and symptoms (e.g., fever, chills, cough, dyspnea, tachypnea, crackles or rales, etc). Note radiological and laboratory findings - include rationale for disagreement with any findings (e.g., negative chest x-ray, culture, etc). Describe preadmission treatment that may have affected radiological or laboratory results (e.g., prior antibiotic use, etc). Document causative agents based on clinical findings, culture results, and/or response to treatment (e.g., gramnegative cocci, Klebsiella because of reddish current jelly sputum, etc). If aspiration pneumonia, note cause of aspiration (e.g., dysphagia, etc). Note patient's current pneumococcal and influenza vaccination status.

Under CMS Program Integrity, one of the differences between a review and an audit is: a.Audits occur every 30 days b.Only contractors perform audits c.Audits are methodological in their approach d.There is no different

c Reviews performed by contractors are usually flexible and broad ranged. Audits are methodological and follow specific standards (CMS 2016d).

The criteria utilized in justifying malnutrition along with treatment and documentation within the health record is: a.Toledo b.KDIGO c.Aspen d.Austria

c The ASPEN criteria is developed by the American Society for Parenteral and Enteral Nutrition on health impact of under and over nourishment (ASPEN 2016).

The CDS review specialist has been performing CDI review on the first day of admission. What impact could this have on the review process? a.None b.Provides the opportunity to capture POA diagnoses c.Can provide little positive impact due to clinical documentation is normally incomplete on the first day. d.Gives the CDS the opportunity for the CDS to add the physician in building the documentation

c The CDI staff 's concurrent record review should begin on the second day after admission. Clinical documentation is normally incomplete on the first day. Review of the record at that time would have little benefit. The CDI manager should consider weekend and holiday coverage (Hess 2015, 176).

Within the Medicare Code Editor, age conflict for maternity edits are: a.10-55 b.15-60 c.12-55 d.16-60

c The Medicare Code Editor lists the age of 12-55 as a maternity edit and should fail billing edits (CMS Medicare Code Editor, 2015).

A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy and a ruptured appendix was discovered. The chief complaint was: a.Ruptured appendix b.Exploratory laparoscopy c.Abdominal pain d.Cholelithiasis

c The abdominal pain is the chief complaint and is the reason the patient presented/reason for visit (Shaw and Carter 2014; Fahrenholz and Russo 2013, 225).

Code 99490 will be utilized to capture chronic care management services for the establishment, implementation, revision, or monitoring of the care plan for patients with at least two chronic conditions, expected to last at least 12 months, and may place the patient at risk of death, exacerbation, or functional decline. This code is reported if, during the calendar month, at least 20 minutes of clinical staff time is spent on care management activities. These codes are: a.Care management codes b.Chronic management time codes c.Chronic care management codes d.None of the above

c The answer is Chronic Care Management Codes. Three new codes have been added to the Evaluation and Management (E/M) section for calendar year (CY) 2015. These are in the Care Management and Advance Care planning subsections. Care Management Services is new this year with extensive notes. This subcategory is for the management and support services provided by clinical staff, under the direction of a physician, to patients at home, in a domiciliary, or in assisted living. Chronic Care Management Services is a new category under the subsection of Care Management Services. Code 99490 will be utilized to capture chronic care management services for the establishment, implementation, revision, or monitoring of the care plan for patients with at least two chronic conditions, expected to last at least 12 months, and may place the patient at risk of death, exacerbation, or functional decline. This code is reported if, during the calendar month, at least 20 minutes of clinical staff time is spent on care management activities (Buttner 2015, 62-64).

A patient arrived via ambulance to the emergency department following a motor vehicle accident. The patient sustained a fracture of the ankle, 3.0 cm superficial laceration of the left arm, 5.0 cm laceration of the scalp with exposure of the fascia, and a concussion. The patient received the following procedures: x-ray of the ankle that showed a bimalleolar ankle fracture requiring closed manipulative reduction and simple suturing of the arm laceration and layer closure of the scalp. Provide CPT codes for the procedures done in the emergency department for the facility bill. 12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm 12004 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm 12032 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm 27810 Closed treatment of bimalleolar ankle fracture (e.g., lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation 27818 Closed treatment of trimalleolar ankle fracture; with manipulation a.27810, 12032 b.27818, 12004, 12032 c.27810, 12032, 12002 d.27810, 12004

c The closed reduction of the fracture is coded first following principal procedure guidelines. The laceration repair is also coded. When more than one classification of wound repair is performed, all codes are reported with the code for the most complicated procedure listed first (Kuehn 2013, 26-27, 111-113).

At times, patients present to the hospital with hematoma. There is noted midline shift of mass effect. Based on the diagnosis, signs or symptoms, and treatment: a.The CDS could consider mass effect query b.The CDS could consider cerebral blood clot query c.The CDS could consider brain compression query d.The CDS could have no considerations

c The coder should query the provider and if the provider clarifies and documents that the mass effect or midline shift is brain compression, the coder may then assign a code for the brain compression (AHA 2011, 11).

The Cooperating Parties, which develop and approve ICD-10, include: a.American Hospital Association (AHA) and American Health Information Management Association (AHIMA) b.American Hospital Association (AHA), American Health Information Management Association (AHIMA), and Centers for Disease Control (CDC) c.American Hospital Association (AHA), American Health Information Management Association (AHIMA), and Centers for Medicare and Medicaid Services (CMS), and National Center for Health Statistics (NCHS) d.American Hospital Association (AHA), American Health Information Management Association (AHIMA), and the World Health Organization (WHO)

c The cooperating parties developed and approved ICD-10-CM/PCS and include (4) organizations American Hospital Association (AHA), American Health Information Management Association (AHIMA), and Centers for Medicare and Medicaid Services (CMS), and National Center for Health Statistics (NCHS) (CMS 2016c).

A patient has a prostate malignancy that had not been excised, removed, and still under treatment. The patient presents to the hospital with irregular heartbeat, malaise and gross hematuria with large amounts of blood being passed via the urethra with the inability to urinate. Patient was noted to have a hemoglobin of 10.8 due to significant blood loss, the patient was transfused and bladder irrigation was begun. Following significant irrigation, urine ran clear. Based on the above scenario, what is the principal diagnosis? a.Blood loss b.Prostate malignancy c.Gross hematuria d.Query warranted to determine the principal

c The diagnosis of gross hematuria should be selected as principal as the treatment was not directed toward the malignancy and the rule of assignment of the principal diagnosis would apply to this circumstance (AHA Second Quarter 2010).

Ms. Smith is admitted with shortness of breath, cough, wheezing, and tachypnea. She had been on handheld bronchodilators, and has a history of chronic obstructive pulmonary disease (COPD). Treatment as an inpatient includes Prednisone, nebulizer treatment, and oxygen at 80 percent. Based on presentation and treatment, this could potentially be a query for: a.Pneumonia b.Acute lung injury c.COPD exacerbation d.Nothing; no need to query

c The patient has a documented diagnosis of COPD and clinical indicators, and treatment that exhibit increased severity and reflection of current state of disease with a query for exacerbation. This is consistent with When and How to Query The generation of a query should be considered when the health record documentation: •Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent •Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis •Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure •Provides a diagnosis without underlying clinical validation •Is unclear for present on admission indicator assignment

A 68-year-old nursing home patient with status post CVA 2 weeks ago presents via the emergency department with a 1-day history of fever, and elevated blood sugars in the 180-210 range. The patient has stated they have significant pain of the right buttock since the previous admission. The patient has a history of diabetes, and is on long-term insulin. On physical exam, it is noted the patient had a fever of 101.3 with purulent drainage with exposure of subcutaneous fat. This type of ulcer can be called a: a.Stage I b.Stage II c.Stage III d.Stage IV

c This is a Stage III ulcer; Full thickness skin loss. The National Pressure Ulcer Advisory Panel (NPUAP) has redefined the definition of a pressure ulcer and the stages of pressure ulcers. (AHA Fourth Quarter 2008, 132)

A patient was admitted for ruptured appendix and an emergent appendectomy was performed. Abscess was noted on visual exam. During the admission, the patient had an MI and a stent was placed. What sequencing order should the procedures be placed in and which should be principal? a.The stent placement is more severe and should be first listed b.The appendectomy is considered incidental c.The appendectomy should be first listed d.Either can be assigned as the principal procedure

c When two definitive procedures have been performed, the for sequencing should be based on the procedure most related to the principal diagnosis as the first procedure to be listed (AHA Fourth Quarter 2012, 80).

Dr. Smith, internal medicine, is the attending physician and his documentation is conflicting with the diagnosis of GI bleed made by the gastroenterologist with no blood on exam. Query is performed due to this conflicting diagnosis. In response to query, Dr. Smith states no history of or present GI bleed. The CDS should: a.Code GI bleed as documented b.Ignore the query c.Utilize the clarification provided by the attending physician for coding d.Code the diagnosis made by the specialist as he would know more about the bleed

c Where there is consistent provider documentation within the record, medical coders can use other parts of the record for final coding. Where there is provider disagreement on the diagnoses or the diagnosis is unclear, coders must always submit a query to clarify. If the two providers cannot agree, the medical coder always uses the attending physician's diagnosis for final coding. Coders must consider a query if the clinical record •Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent •Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis •Includes clinical indicators, diagnostic evaluation, or treatment unrelated to a specific condition or procedure •Provides a diagnosis without underlying clinical validation •Is unclear about present on admission indicator (POA)

A facility has a MSDRG utilization rate of 85 percent of MCCs for a specific MSDRG. This could indicate: a.underutilization b.overutilization c.a compliance risk d.both Band C

d A higher utilization of a specific DRG in comparison to peers could indicate a documentation/coding issue (Hess 2015, 90).

A physician query may be appropriate in which of the following instances? a.Diagnosis of diastolic heart failure noted in the progress notes and echocardiogram showing systolic dysfunction with cardiomegaly b.Discharge summary indicates chronic pancreatitis but the progress notes document acute pancreatitis throughout the stay c.A colonic mass was removed via colonoscopy and sent to pathology. The diagnosis of malignant carcinoma of the colon mass when pathology states no malignancy d.All of the above

d A query may be appropriate because the clinical information or clinical picture does not appear to support the documentation of a condition or procedure. In situations in which the provider's documented diagnosis does not appear to be supported by clinical findings, a healthcare entity's policies can provide guidance on a process for addressing the issue without querying the attending physician (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 348).

On presentation, patient noted to clinical appearance of chills, weakness, and hypotension, with systolic BP noted in the 80s and 90s at 85/61, Temperature 37.1 degrees. The patient had urine showing blood, protein, leukocytes, and WBCs of 12,000 with 10 percent bands. Patient with urinary tract infection and pneumonia with noted infiltrate on x-ray and crackles at the bases. The patient had altered mental status and was unaware of family members. Patient had respiratory difficulty requiring 4 liters nasal cannula at 88-93 percent saturation; RR 20. Laboratory shows creatinine increase from 1.28 to 1.8 Elevated blood sugar at 154; Urine bilirubin 2.0. Fluid resuscitation was initiated uneventfully leading to treatment with Vasopressor—Levophed for symptoms related to sepsis. Antibiotic coverage for severe infection—Azithromyzin to Vancomycin, Levaquin, and Zosyn. What diagnosis should be queried? a.Gram negative pneumonia b.None; no query is warranted c.Severe sepsis d.Severe sepsis with shock

d A subset of people with severe sepsis will develop hypotension despite adequate fluid resuscitation. These patients may develop the perfusion abnormalities previously noted with Sepsis which may include lactic acidosis, oliguria, or an acute alteration in mental status. Patients receiving vasopressor agents such as Levophed or dopamine may not be hypotensive by the time that they manifest hypoperfusion abnormalities or organ dysfunction (AHIMA 2008).

A set of activities designed to familiarize new employees with their jobs, the healthcare entity, and work culture is called: a.Training b.Job analysis c.Job rotation d.Orientation

d After employees have been recruited and selected, the first step is to introduce them to the organization and their immediate work setting and functions. New employee orientation includes a group of activities that introduce the employee to the organization's mission, policies, rules, and culture; the department or workgroup; and the specific job he or she will be performing (Shaw and Carter 2014; LaTour et al. 2013,731).

Altering the route of passage of the contents of a tubular body part is: a.Division b.Alteration c.Change d.Bypass

d Bypass means rerouting contents of a body part to a downstream area of the normal route, to a similar route and body part, or to an abnormal route and dissimilar body part. It includes one or more anastomoses, with or without the use of a device (Zeisset 2013, 40).

It has been brought to the attention of the compliance officer that codes are being rejected as unacceptable principal diagnoses. Compliance should a.Not worry about the problem b.Ensure the coding is accurate c.Follow up with the Medicare Administrative Contractor (MAC) d.Both b and c

d Compliance should validate the coding is accurate follow with the MAC. It may also be beneficial to obtain a policy related to the guidance (Leon-Chisen 2012).

Conventions, general coding guidelines, and chapter-specific guidelines are utilized in a.The clinic setting only b.Within the hospital setting c.Within rehabilitation centers d.All of the above

d Conventions, general coding guidelines, and chapter specific guidelines are utilized within all settings (Zeisset 2013, 35).

The CDS manager has been asked to assist with assessing or managing data quality for internal external customers. This role is called the: a.Chief Information Officer b.HIM director c.Quality analyst d.Data manager

d Data manager. When tasked with assessing or managing data quality, an HIM professional must first understand who the data consumers are. This involves making a list of all of the internal and external consumers. Assessing the needs of data consumers is challenging; a good data manager would ask the data consumer how they use the data rather than what their needs are. The data manager must take a controlled and careful approach to collecting data for consumer needs. It will be impossible for the data manager to meet all the needs of all of the data consumers (Fenton and Biedermann 2014, 114-115).

When a pregnant patient presents for a condition, it is important to determine: a.If the condition of the mother that existed prior to pregnancy (pre-existing). b.If the condition developed during or is due to the pregnancy. c.If no additional information is needed for appropriate diagnosis selection. d.Both a and b

d Pre-existing conditions versus conditions due to the pregnancy Certain categories in Chapter 15 distinguish between conditions of the mother that existed prior to pregnancy (pre-existing) and those that are a direct result of pregnancy. When assigning codes from Chapter 15, it is important to assess if a condition was pre-existing prior to pregnancy or developed during or due to the pregnancy in order to assign the correct code. Categories that do not distinguish between pre-existing and pregnancy related conditions may be used for either. It is acceptable to use codes specifically for the puerperium with codes complicating pregnancy and childbirth if a condition arises postpartum during the delivery encounter (CMS 2016b).

A set of indicators providing information on potential in hospital complications and adverse events following surgeries, procedures, and childbirth: a.Core measures b.Healthcare Effectiveness Data and Information Set (HEDIS) c.Physician Quality Reporting System (PQRS) d.Patient Safety Indicators (PSI)

d The Patient Safety Indicators (PSIs) are a set of indicators providing information on potential in hospital complications and adverse events following surgeries, procedures, and childbirth. The PSIs were developed after a comprehensive literature review, analysis of ICD-10-CM codes, review by a clinician panel, implementation of risk adjustment, and empirical analyses (AHIMA 2015; AHRQ 2015).

The _________ diagnosis is designated and defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital a.Secondary b.DRG diagnosis c.Most resource intensive d.Principal

d The Principal diagnosis should be assigned as the first-listed diagnosis for the hospital admission as the cause of the hospital stay after study and evaluation by the responsible physician (ICD-10-CM Official Coding Guidelines 2016b, 88).

If a service is determined to be reasonable and necessary for the related diagnosis or treatment of illness or injury, it is stated as being: a.Needed for treatment b.Medically justified c.Non-covered d.Medically necessary

d The determination that a service is reasonable and necessary for the related diagnosis or treatment of illness or injury is determined to be medically necessary (Shaw and Carter 2014; Malmgren and Solberg 2011, 462).

In outpatient CDI reviews, it would be appropriate to report all the following diagnosis except: a.Chest pain b.Dizziness c.Evidence of pneumonia d.Appears to be bronchitis

d The phrase "appears to be," listed in the diagnostic statement fit the definition of a probable or suspected condition and would not be coded in the outpatient setting. The Official Guidelines for Coding and Reporting, Section IV.I. state, "Do not code diagnoses documented as 'probable,' 'suspected,' 'questionable,' 'rule out,' or 'working diagnosis' or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit." In terms of coding and reporting for hospital inpatients, according to the Official Guidelines for Coding and Reporting, Section III.B., it would not be appropriate to code abnormal findings from radiology reports. However, when the provider documents "evidence of a particular condition, it is not considered an uncertain diagnosis and should be appropriately coded and reported in the outpatient setting (AHA Third Quarter 2009, 7 and CMS 2016b, Section IV.I).

The recovery auditor performed a review of 20 inpatient records. In review of the audit findings, it was determined the denials all had a common target. Review the denial summary below and determine what was targeted by the auditors: • 186 MED PLEURAL EFFUSION W MCC • 190 MED CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC • 291 MED HEART FAILURE & SHOCK W MCC • 388 MED G.I. OBSTRUCTION W MCC a.Review of medical DRGs b.Review of LOS greater than 2 days c.Review of DRGs with MCC d.Both a and c

d The summary of DRGs review all related to Medical DRGs with a MCC. Review CMS DRG table for a list of current DRGs (CMS 2016a).

Anywhere Hospital has implemented a clinical documentation improvement program. The Director of CDI along with the CMO has decided they will focus on all targets for documentation improvement. This is: a.Incorrect as CDI focuses only on Medicare patient populations. b.Incorrect as CDI focuses only on commercial patient populations. c.Incorrect as CDI requires a focus on both populations. d.Appropriate as CDI initiatives are dependent on the needs of documentation improvement for each individual facility.

d There is no requirement for a CDI program to focus on a specific payer for CDI initiatives. The focus is dependent on individual organizational needs (AHIMA 2014a, 2).

A 18 year-old male was admitted with exacerbation of asthma. To assign this diagnosis for coding, the diagnosis should be clarified for: a.Mild persistent b.Persistent persistent c.Moderate persistent d.Unspecified e.All of the above

e All of the diagnoses listed could further describe the state of the patient's asthma. (CMS 2016b)

Drug therapies for heart disease treatment include: a.Vasodilators b.Beta blockers c.Calcium channel blockers d.Both a and b e.a, b, and c

e It is important that you can identify medications as there may be treatment performed with unclear documentation and the need to query for certain conditions, if there is clinical indications and treatment (AHIMA 2015; Heart.org 2015).

Diabetes is a condition that exists when glucose (blood sugar) levels are above the normal range. Which of the following drugs are treatments for diabetes? a.Amaryl b.Metformin c.Avandia d.a and b only e.b and c f.a, b, and c

f Amaryl (glimepiride) second generation sulfonylureas, Metformin (glucophage) and Avandia (rosiglitazone) decrease the amount of glucose produced by the liver (AHIMA 2015).