Question 1

All entries in the medical record must be legible. These entries include written progress notes, nursing notes, physical therapy, occupational therapy, speech therapy, consultations, and other notes that are handwritten in the patient's medical record to support the treatment provided during the visit or stay.

Accepted Answer

Legible entries in the medical record are crucial for ensuring accurate communication among healthcare providers, facilitating continuity of care, and supporting billing and legal documentation. Illegible handwriting can lead to errors in patient treatment and misunderstandings among care team members.

Question 2

To be able to effectively code a medical record for a hospital stay or visit to a facility, the entries must be complete and contain sufficient information to identify the patient; support the diagnosis and condition; justify the care, treatment and services; document the course and results of care, treatment, and services; and promote continuity of care among providers.

Accepted Answer

Accurate and complete medical record documentation is essential for effective coding, as it ensures that all aspects of a patient's care are properly recorded, justified, and can be followed by other healthcare providers, thereby supporting the billing process and continuity of care.

Question 3

When the EMR system only puts the date and time that the document was created, but not the date and time when the practitioner viewed it, then the practitioner does not need to authenticate the document or acknowledge that the document was reviewed.

Accepted Answer

The practitioner is still required to authenticate or acknowledge the document to confirm they have reviewed it, regardless of whether the system records the viewing time. Authentication serves as a legal attestation to the accuracy and completeness of the information within the document.

Question 4

Health records are legal business records and must be maintained following federal and state regulations to ensure that the information, if accessed, is accurate and complete.

Accepted Answer

Health records are indeed considered legal business records and are subject to federal and state regulations to ensure their accuracy, completeness, and confidentiality. These regulations include laws such as the Health Insurance Portability and Accountability Act (HIPAA) in the United States, which sets standards for the protection of sensitive patient health information.

Question 5

The ICD-9-CM guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself. These guidelines are based on coding sequencing instructions found in the three volumes of the ICD-9-CM, but provide additional instruction.

Accepted Answer

The ICD-9-CM guidelines serve as a comprehensive guide designed to assist health professionals in coding medical diagnoses and procedures accurately, complementing the instructions found within the three volumes of the ICD-9-CM with additional, detailed guidance.

Question 6

The ICD-10-CM is a morbidity classification published by the United States for classifying diagnoses and reasons for visits in all healthcare settings.

Accepted Answer

The ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) is indeed a morbidity classification system used in the United States for coding and classifying diagnoses and reasons for visits in all healthcare settings.

Question 7

The term "encounter" is used for all settings and is a professional, direct personal contact between a patient and a physician or other person who is authorized by state licensure law.

Accepted Answer

The term "encounter" indeed refers to a professional, direct personal interaction between a patient and a healthcare provider, such as a physician, who is authorized to practice as per state licensure laws. This encompasses various settings and situations where healthcare services are provided.

Question 8

The term "Late Effect" is a residual effect or a condition produced, before the acute phase of an illness or injury has terminated.

Accepted Answer

The term "Late Effect" refers to a condition that appears after the acute phase of an earlier, causal illness or injury has ended, not before.

Question 9

If a patient is admitted to an observation unit in a hospital for a medical condition and either does not improve or the condition worsens and is then admitted to the hospital as an inpatient, the coder will use the principal diagnosis as the condition that led to the actual hospital admission.

Accepted Answer

The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Therefore, if a patient's condition worsens or does not improve while in an observation unit leading to inpatient admission, the principal diagnosis would be the condition that necessitated the inpatient admission.

Question 10

If a patient receives outpatient surgery and is admitted to the same hospital as an inpatient, the principal diagnosis for the admission will be based on the reason for the inpatient admission.

Accepted Answer

The principal diagnosis for the inpatient admission is determined by the condition that after study is found to be chiefly responsible for the patient's need for hospital care, which may differ from the reason for the outpatient surgery.

Question 11

If no complications or other conditions are documented as the reason for the inpatient admission after observation, then the coder does not need to assign the reason for the outpatient surgery as the principal diagnosis.

Accepted Answer

The reason for the outpatient surgery can still be relevant and necessary to assign as the principal diagnosis if it directly led to the inpatient admission, even if no complications or other conditions are documented during the observation period. The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Question 12

If the reason for inpatient admission after observation is another condition that is unrelated to the surgery, the coder will assign the unrelated condition that caused the admission as the principal diagnosis.

Accepted Answer

The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. If the reason for inpatient admission is unrelated to the condition that prompted the observation or surgery, the unrelated condition causing the admission should be coded as the principal diagnosis.

Question 13

The HCPCS system was involuntary in the beginning, however, with the implementation of HIPAA, the use of HCPCS for transactions involving healthcare information became mandatory.

Accepted Answer

The answer of The HCPCS system was involuntary in the...

Question 14

Modifiers are two-digit alpha or alphanumeric codes. A modifier is designed to give Medicare and other third-party payers additional information needed to process a claim.

Accepted Answer

Modifiers are indeed two-digit codes, either numeric or alphanumeric, used in medical billing to provide additional information to Medicare and other third-party payers for claim processing.

Question 15

The levels of E/M services include examinations, evaluations, and treatments; conferences with or concerning patients; preventive pediatric and adult health supervision; and similar medical services such as the determination of the need and/or location for appropriate care.

Accepted Answer

E/M (Evaluation and Management) services encompass a broad range of healthcare services including examinations, evaluations, treatments, and consultations, among others, aimed at determining the best course of care for patients.

Question 16

Hospital observation services are provided to patients who are designated as admitted to an "observation status" in a hospital. It is not necessary that the patient is located in the observation unit or area designated by the hospital. If an observation area is not present in the hospital, then the coder will assign these codes as if the patient was placed in such a unit.

Accepted Answer

Observation services can be provided to patients in various parts of the hospital, not just in a designated observation unit. The key factor is the patient's status as "under observation," which determines the coding, rather than the physical location within the hospital.

Quiz 9: Coding for the Non-Him Professional