CDEO QUESTIONS & ANSWERS VERIFIED 100% CORRECT

Which system is given credit for the exam component when a provider documents "no appreciable edema in the ankles?" - Cardiovascular When providing CDI to a provider, does the message change depending on whether you are performing a prospective or retrospective audit? - Yes, because the auditor cannot ask leading questions regarding documentation before a claim is submitted. The surgeon documents liver cancer, but the pathology report states angiosarcoma of liver. You: - Code the liver cancer as angiosarcoma, a primary liver cancer, based on the pathologist's documentation. Clinical Documentation Improvement (CDI) programs can help: - - Build effective documentation compliance policies - Capture clinical data required for continuity of care documentation deficiency that has a negative impact on patient outcomes - Failure to include the complications of drug for prescriptions taken by a patient. What is best practice to communicate document deficiencies to a provider? - Provide examples of the provider's documentation errors with suggestions for improvement. A physician who specializes in elder care undergoes a CDI audit. Fifteen charts are found with the diagnosis of marasmus. Your correct response: - Display in your query the Index entry for marasmus and the codes and descriptions for E41 and R54. Ask for guidance on which to report. The best approach when querying a physician regarding documentation is to approach the problem as one of: - - Evidence based medicine - Financial motive - Malpractice liability - Documentation impact on reimbursement- Documentation impact on compliance Which EMR feature is non-compliant with CMS? - Templates that allow the provider to de-select a prepopulated "normal" checkmark when the system is abnormal in the ROS What is NOT considered a purpose of documentation improvement programs? - Increase reimbursements CDI programs can help with: - Consistency of documentation & Team building Which is NOT an acceptable cause for query? - Signs and symptoms without a diagnosis Which is a leading query? - Your sarcoidosis patient has sarcoid lesions on the cerebral cortex, correct? In reviewing the provider's assessment the documentation states "lab tests reviewed: +K." You correctly query: - Can you please address the patient's potassium status in further detail? Documentation states: Patient has a history of a recent myocardial infarct and is admitted today with an ST elevation MI of the anterior wall. The flaw in this documentation from a coding standpoint: - The duration between the recent myocardial infarct and the current myocardial infarct will impact coding, so "recent" is insufficient documentation Which term or phrase, when used between a manifestation and etiology, does NOT always show a causal relationship? - likely Which is an example of poor documentation that is especially problematic as there is no "unspecified" code for the condition in ICD-10-CM? - Degenerative disc disease (DDD)When reviewing documentation and you notice information is missing, what is the proper procedure? - The information should be added as a documented late entry/addendum only when necessary. Is it an acceptable practice to use a template that always documents a complete review of systems? - No. The extent of ROS performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s). Which type of documentation can be used to report diagnoses under risk adjustment models? - Inpatient Admission Note What type of payment does an ACO (Accountable Care Organization) receive? - An ACO receives reimbursements based on quality metrics and reductions in the total cost of care for an assigned population of patients. Which statement is TRUE regarding RAFs? - A patient with a RAF score of 3.09 will likely consume more health care in the coming year than a patient with a RAF score of 1.89. Documentation for 9/1/20XX OV: CHIEF COMPLAINT: follow-up on Dr. Kundeling's visit. HPI: Tim is here for a follow-up. Overall he has been doing well. His energy level has not changed much from the other time, but overall he is doing well. He does not have any acute complaints. When he saw Dr. Kundeling, he was put on a new medication. Unfortunately, he does not recall the name. He seems to be tolerating it well. ROS: Today is a negative for back pain, energy level unchanged from the last time, no nausea or vomiting, also lower leg edema is unchanged. O: Blood pressure is 118/60, respirations are 20, elevated pulse of 128, temperature is 98.0, and weight is 213 pounds. In general, Tim is a very pleasant male in no acute distress. He is alert. He responds to questions appropriately. A/P: At this time, I think any past fatigue could be related to his past history of anemia and hypothyroidism. However, given the fact tha - - No chief complaint - No diagnoses in assessment - Pulse rate is not discussed in assessment- "Past history" disorders are likely current problems - Entire note seems very vague A patient with ESRD on dialysis comes in with an infection at the peritoneal dialysis catheter site. The provider evaluated the infected skin and determined a staph infection. The provider prescribed antibiotics and performed a dressing change. What are the correct codes and sequence? - T85.71XA, L08.89, B95.8, N18.6, Z99.2 Which of the following information should be documented to properly code hypertension in ICD-10-CM? - Type (essential, secondary) The patient is documented as a cigarette smoker. The correct code: - F17.210 Which statement is TRUE for the use of a sign/symptom code with a definitive diagnosis code? - Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. When would morbid obesity be considered clinically significant: - Morbid obesity is always clinically significant and reportable if documented by the provider. Which code systems are included in HEDIS? - CPT® CDT HCPCS Level II Which of the following is a HEDIS measure? - Adult BMI Assessment Cervical Cancer Screening Breast Cancer Screening Which CPT® code submitted on a claim would support the lead screening in children HEDIS measure? - 83655A patient is diagnosed with acute on chronic gastrointestinal bleeding due to a small bowel peripheral arteriovenous malformation (AVM). Documentation does not indicate whether the AVM is acquired or congenital. What is the correct ICD-10-CM code to report? - K55.21 How is the cost category under MIPS going to be determined? - Adjudicated claims A 4 year-old is getting over his cold and will be getting three immunizations in the pediatrician's office by the nurse. The first vaccination administered is the Polio vaccine intramuscularly. The next vaccination is the live influenza (LAIV3) administered in the nose. The last vaccination is the Varicella (live) by subcutaneous route. What CPT® codes are reported for the administration and vaccines? - 90713, 90660, 90716, 90471, 90472, 90474 Patient has a suspicious lesion of the right axilla. The area was infiltrated with local anesthetic and prepped and draped in a sterile fashion. With the use of a 3 mm punch tool the total lesion with margins was excised and closed with 5.0 Prolene suture. Pathology report indicated this was a seborrheic keratosis. What CPT® and ICD-10-CM codes are reported? - 11400, L82.1 Acute and Chronic Respiratory Failure with Mild Hypoxemia How many codes would be required to report the respiratory failure? - One: Report acute and chronic respiratory failure unspecified whether with hypoxia or hypercapnia a status code for a BKA is informative because the status... - may affect the course of treatment and its outcome These would be reported as a history of breast cancer rather than active breast cancer - -Breast cancer, post mastectomy, on tamoxifen prophylaxis -Breast cancer, post mastectomy, now undergoing prophylactic contralateral mastectomy -Breast cancer, post mastectomy, undergoing chemotherapy for secondary bone cancer Consider the following final diagnostic statement: Acute renal failure in patient with history of renal transplant. What advice would you give to the provider regarding whether this documentation is sufficient to document a kidney transplant complication. - Conditions that affect the function of a transplanted kidney, other than CKD, can be established as kidney transplant complications. Acute renalfailure would affect the function of the kidney transplant and it would be appropriate to assign a kidney transplant complication code. COPD can be exacerbated by - -Viral bronchitis -Pneumonia -Inhalation of irritable substances such as smoke Diabetic ulcers are staged by - -Skin -Subcutaneous tissue -Muscle -Bone What are common signs and symptoms of a patient presenting with deep vein thrombosis (DVT)? - Swelling in the leg According to documentation, A 34-week gestation patient with diabetes delivers twins. Fetus A was delivered without complication, with APGARs of 8 and 8. Fetus B's delivery was complicated by a knot in the umbilical cord, and his APGARs were 3 and 5. Which query is appropriate? - What type of diabetes did the patient have? The provider states that the patient is hypertensive and is interested in beginning a diet. He discusses weight loss strategies, but does not document that the patient is overweight, obese or morbidly obese. BMI documented in the vitals is 42, blood pressure 145/82. The patient receives a prescription for amlodipine. You: - Query the provider, asking if there is a diagnosis to go with the weight loss strategy counseling that was performed.