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 ...
CDEO
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.
- 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)
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