AHIMA
explain the process a coder must follow when conflicting documentation exists correct answerspatients
who are admitted to an inpatient status in the hospital may be assessed by multiple physicians.
inevitably, the documentation of the various physicians will conflict. for example, the attending physician
may document acute renal failure, but the nephrology consultant documents acute renal failure., but the
nephrology consultant documents acute renal disease. since failure and disease in this particular case
equate to different codes, the coder will need clarification, and that clrification is best achieved through
the initiation of a query. the query would need to reveal the conflicting information and ask for the final
decision as to which diagnosis is correct, other clinical indicators should be a part of thr query in order to
demonstrate to the physician why the information is conflicting. for example, in this acute renal failure
versus disease scenario, the coder may choose to include the clinical indicators pertaining to a rise in the
bun\creatinine as well as the urine output amounts.
you are a member of hospitals HIM committee. the committee has created a HIPAAcompliant
authorization form which of the following items does the privacy rule require for the form? correct
answersidentification of the person oe entity authorized to receive PHI
provide examples of a leading query correct answersleading provider\physician queries are not
acceptable in healthcare. following are examples of inappropriate leading queries: a query that
providesthe physician with options that only leadto additional reimbursement. a query that does not
contain all the required clinical indicators to paint the full clinical picture of the patients condition. a
query wherein the statements are directive in nature, such as indicating what the provider should
document, rather than querying the provider for his\her professional determination of the clinical facts.
a query that leads the provider to one desired outcome. a query that omits reasonable clinically
supported options. a query that omits an option that no additional documentation or clarification may
be provided.
explain the 4 major attributes of icd 10 pcs codes correct answersthe structure of icd 9 cm colume 3 for
procedural coding was not capable of involving into more codes necessary for keeping up with the
explosion of technological advances in healthcare. it became mandatory in the icd 10 realm for
procedural codes to be designed in such a way as to accomodate growth long term. the results was icd
10 pcs with elimination of a third volume. icd 10 pcs was developed with 4 major attributes and their
meaning in mind: completeness (meaning one unique code for each different procedure) expandibility
(meaning- icd 10 pcs allows for the incorporation of new procedure codes ) multiaxial (meaning-codes
consist of independent characters with the capability of each retaining meaning across broad ranges of
codes) and standardized terminology (meaning0=-each term must have a specific meaning) it is
,important that coders thoroughly understand the definitions for all the procedures and the various
approaches to operations as this will be key to correct code assignments.
briefly explain how a mentoring plan for new coders might be implemented correct answerswith the
advent of icd 10 in Oct 2015, new coding challenges surfaced. many seasoned or experienced coders
retired, and new coder interest was insufficient. many healthcare entities have been forced to develop
training plans for new coders. these training plans may include a mentorship. an ideal mentorship
program would be strucutred in the following manner: assign a mentor ( an experienced coding
professional) to 2 new coders. the mentor will then review 100% of all coded accounts by the new
coders prior to billing. the mentor will provide educational feedback should always reference applicable
medical information and\or coding clinic references. time should be allotted for the new coders to
review the feedback, hold discussions, and review multiple training resources. a key component of this
training plan is open communication, especially if mentors and coders work in remote environments.
elaborate on this adage " if it isnt documented , it hasnt been done" correct answersthe statement has
been a longstanding adage well known to health information professionals. healthcare provider
documentation of diagnoses and treatment rendered is the key to preventing denials, winning appeals,
and preventing accusations of fraudulent activity by governmental agencies. the center for medicare and
medicaid services points out that clear and concise health information documentation is critical to the
quality of patient care and is required for payment of services rendered. documentation is necessary to
support the medical necessity of services and to ensure compliance with regulatory requirements.
healthcare organizations must have policies and procedures in place to maintain the integrity of the
health record.
discuss the intent of a physician query correct answersa physician query is a tool of communication
between CDI specialist\ coders and physicians to clarify incomplete, ambiguous, or conflicting
documentation in the medical record. the intention of the communication tool is to facilitate
completeness, accuracy, consistency, and timely documentation for coding, and reporting practices.
queries are an essential tool and provide additional clariffication that allows coding and reporting to the
highest level of specifity. it is best for the physicians query to be maintained as a permanent part of the
medical record since it is considered to be supporting documentation for assigned codes.
explain enterprise content and records management (ECRM) correct answersenterprise content and
records management (ECRM) can be defined as the management of electronic information created and
stored in analog or digital format, with the records management component referring to the creation,
receipt maintenance, use and disposition of the health information. to manage health information\
health record content at an enterprise level, various technologies, tools, and methods will be used to
create,store,maintain, and deliver the health information. the life cycle begins with the creation of
information with the source of creation being an email, paper, or other knowledge source. the newly
created health information is reviewed and edited until a final version is published via electronic health
, record systems, corporate portals, cd roms, or pdf collections. the final version will move through a stage
of active use until it becomes inactive and is retained until approved for a final disposition. ecrm tools
and technologies aid healthcare entities with record management processes. these tools may include bar
coding, optical character recognition, classification tools, and computer output tools to laser disks.
discuss the options available for query formatting correct answersthere are several ways to generate a
query : compliant query forms allow for open-ended questions, multiple choice query formats, and\or
limited yes\no query formats. an example of open-ended query might appear in this format. based on
your clinical judgement, please providea diagnosis that represents the following clinical indicators:
temperature 102, cellulitis around ankle with open wound, white blood cell count 15,000. an example of
a multiple choice query might appear in this format: per the discharge summary, the patient has
congestive heart failure (CHF)can the chf be further specified as 1) acute systolic CHF. 2 ) acute on
chronic systolic CHF 3) acute diastolic CHF 4) acute on chronic diastolic CHF 5) undetermined. an example
of a yes\no query might appear in this format was the sepsis documented in the discharge summary
present on admission? yes, no, clinically unable to determine.
discuss the meaning and purpose of IGPHC correct answersAHIMAs information governance principles
for healthcare (IGPHC) is an organization wide framework for healthcare entities to follow when
governing information management strategies. the framework or model can be used for program
development for benchmarking. it is based on the following 8 principles
accountability- an individual at the healthcare administrative level is given the responsibility of overseer
of the information governance plan.
transparency- information governance practices should be available for review at any time with an audit
trail available to verify activities.
integrity-healthcare information will meet authenticity and reliability expectations.
protection-healthcare information will be protected against breaches, corruption, and loss.
compliance- information governance will meet regulatory requirements.
availability- information will be retrieved in a timely and efficient manner.
retention- information will be retained\mainatined according to legal time frame requirements.
disposition- information will be appropriately disposed of, after legal time frames have passed.
identify steps involved in building a successful team correct answersbuilding a team to a level of success
will hinge on how well the leader enables each team member to reach his\her best potential and goals.
through team approaches, healthcare entities can experience increased production, customer
satisfaction, cost savings, and goal achievements. leaders should build teams by establishing goals and
