CCDS Healthcare Documentation 2 — Questions and Answers
Question 1: Which of the following is considered a 'qualified provider' who may document diagnoses for ICD-10-CM coding purposes in the inpatient setting?
- Registered nurse documenting in the nursing care plan
- Attending physician or other qualified healthcare practitioner legally accountable for the patient's care (Correct answer)
- Physical therapist documenting in the rehabilitation notes
- Pharmacist documenting in the medication reconciliation record
Correct answer: Attending physician or other qualified healthcare practitioner legally accountable for the patient's care
Per ICD-10-CM guidelines, diagnoses must be documented by the attending physician or other qualified healthcare practitioners who are legally accountable for establishing diagnoses in the inpatient setting.
ICD-10-CM Official Guidelines specify that diagnoses must be documented by the attending physician or other qualified provider who is legally accountable for establishing the patient's diagnosis. In practice this includes attending physicians, treating specialists, residents per facility policy, and advanced practice providers within their scope of practice.
Question 2: A discharge summary that conflicts with the body of the medical record should be handled in which of the following ways?
- Always defer to the discharge summary as the most authoritative document
- Query the physician to resolve the discrepancy before finalizing the coded record (Correct answer)
- Code based on whichever documentation supports the higher DRG
- Use the conflicting information to code two separate diagnoses
Correct answer: Query the physician to resolve the discrepancy before finalizing the coded record
When the discharge summary contradicts information in the body of the record, the physician should be queried to clarify and reconcile the conflict before coding.
Conflicting documentation creates a compliance risk because selecting between contradictory entries without physician clarification constitutes a coder judgment on clinical matters outside the scope of coding practice. The appropriate action is a post-discharge query asking the physician to review the conflicting entries and provide a clarifying addendum.
Question 3: Which of the following documentation elements is REQUIRED by CMS Conditions of Participation for all inpatient medical records?
- Nutritional assessment completed within 24 hours of admission
- Authenticated history and physical completed within 24 hours of admission or prior to surgery (Correct answer)
- Daily physician progress notes co-signed by the attending
- Nursing care plan updated every shift for the entire hospitalization
Correct answer: Authenticated history and physical completed within 24 hours of admission or prior to surgery
CMS Conditions of Participation require that a history and physical examination be completed and authenticated within 24 hours of admission or before any surgery.
CMS Conditions of Participation require hospitals to maintain medical records for every patient that include an authenticated history and physical completed no more than 30 days before admission or within 24 hours of admission, and in all cases before any surgery is performed.
Question 4: A physician uses the term 'urosepsis' in documentation. How should a CDI specialist respond?
- Code as sepsis due to urinary tract infection directly
- Query the physician to clarify whether a UTI, sepsis due to UTI, or another condition is intended (Correct answer)
- Accept the term and code as unspecified sepsis (A41.9)
- Document that urosepsis is the principal diagnosis without further review
Correct answer: Query the physician to clarify whether a UTI, sepsis due to UTI, or another condition is intended
The term 'urosepsis' is not a codeable ICD-10-CM term and has been used inconsistently to mean anything from a UTI to sepsis due to UTI. The CDI specialist must query the physician to clarify the intended clinical meaning before coding.
Urosepsis is a non-specific term not recognized by ICD-10-CM, and its meaning varies widely among clinicians. The coding community and CDI guidelines are clear that 'urosepsis' must be queried to determine the physician's clinical intent.
Question 5: Under HIPAA, which role has the authority to release a patient's medical records to a CDI specialist for documentation review?
- Any hospital employee who requests access for quality improvement
- The CDI specialist has inherent access as a member of the healthcare operations team (Correct answer)
- Only the patient's attending physician after written patient authorization
- The hospital compliance officer upon receipt of a formal written request
Correct answer: The CDI specialist has inherent access as a member of the healthcare operations team
HIPAA permits covered entities to use patient health information for treatment, payment, and healthcare operations without patient authorization. CDI activities fall under healthcare operations.
HIPAA's Privacy Rule permits covered entities to use and disclose protected health information for healthcare operations without individual patient authorization per 45 CFR 164.506. CDI is explicitly categorized as a healthcare operations function.
Question 6: Which element of a physician's documentation would MOST clearly support coding of a complication of care in the inpatient setting?
- A nurse's incident report documenting a medication administration error
- An attending physician's progress note stating 'patient developed postoperative wound infection' (Correct answer)
- A pharmacist's note identifying a potential drug interaction
- A radiology report describing a finding consistent with a wound complication
Correct answer: An attending physician's progress note stating 'patient developed postoperative wound infection'
Only physician documentation can support coding a complication of care. An attending progress note explicitly stating the patient developed a postoperative wound infection is the documentation basis needed to code the complication.
Coding complications of care requires physician documentation because complications have significant impact on quality metrics, HAC reporting, and DRG assignment. Nursing incident reports, while important for risk management, do not constitute codeable diagnoses.
CCDS Healthcare Documentation 2
Which of the following is considered a 'qualified provider' who may document diagnoses for ICD-10-CM coding purposes in the inpatient setting?