Chapter 4 — Exercises

Items marked † have worked solutions in Answers to Selected Exercises, along with every odd-numbered item. All clinical documentation in these exercises is constructed.

A. Recall and vocabulary

4.1 State, in one sentence, the relationship between a code and a medical record.

4.2 Name the sections of an office note and say what each contributes to code assignment.

4.3 † Which section of a note is the primary source of diagnosis codes, and why is it not the chief complaint?

4.4 Why must the body of an operative report be read even when the heading names the procedure? Give three specific things the body can contain that the heading cannot.

4.5 State the authentication requirements for documentation. Name four signature-related defects that cause a claim to fail on review.

4.6 † Distinguish an addendum, a late entry, and an amendment. State the principle all three must satisfy.

4.7 Name the three distinct ways cloned documentation creates a problem, and say which one is a patient safety issue before it is a billing issue.

4.8 State the rule for when a code may be assigned. Then name the three kinds of inference the rule forbids.

4.9 † Distinguish the legal health record from the designated record set. Which is generally broader, and why does a coder care?

4.10 List five circumstances that justify a query and four that do not.

4.11 Name the four requirements a compliant query must satisfy.

4.12 State the seven-step method for reading a note from §4.10, in order.

B. Read the document

4.13 † A note reads, in its entirety for the relevant problem:

  ASSESSMENT: Diabetes. Continue current regimen.

The problem list carries "type 2 diabetes mellitus" and "chronic kidney disease, stage 4." The medication list includes insulin. What can you code, what can you not code, and what would you query?

4.14 A procedure note reads: "Lesion excised from the back. Specimen to pathology. Wound closed." List every element the code set will require that this note does not supply.

4.15 † An operative report is headed "Procedure performed: laparoscopic cholecystectomy." The body describes adhesiolysis requiring 45 additional minutes, an intraoperative cholangiogram, and conversion to an open procedure after two hours. Which of these facts could affect coding, and what does the exercise demonstrate about headings?

4.16 A note's HPI states the patient "was told by another doctor that she has rheumatoid arthritis." The assessment reads "joint pain." What do you code, and why?

4.17 † A note documents a comprehensive twelve-system review of systems and a complete examination. The visit lasted nine minutes according to the appointment record, and the patient was seen for a medication refill. State the problem, the compliance exposure, and what you would do.

4.18 Two notes for the same patient, four weeks apart, are identical word for word in the examination section including a finding that was surgically corrected in between. Describe the conversation you would have and with whom.

C. Queries

4.19 † Rewrite this as a compliant query:

"Doctor — the patient was on IV antibiotics for four days and had a fever of 102. Can you add 'sepsis' to the assessment? Without it the DRG is much lower."

4.20 Write a compliant query for a note that documents "cellulitis" without a site or laterality, where the examination describes erythema of the left lower leg.

4.21 † A provider responds to your query with "possible acute blood loss anemia." State what you may code in an outpatient setting and what you may code in an inpatient setting, and name the rule that makes them different.

4.22 Your query template offers two options: the diagnosis you believe is correct, and "other." Explain why this is a leading query despite technically offering a choice, and fix it.

4.23 † A coder sends a query, receives no response for eleven days, and the claim is approaching a timely filing deadline. Describe the options, in order of preference, and state which one is not available.

D. Judgment and process

4.24 A physician tells you: "I'm not adding anything to that note. I documented what I did. If they don't want to pay, that's their problem." Give your response.

4.25 † A payer requests records for twelve claims. Your supervisor asks you to review each chart first and have the providers "fill in anything that's thin." State your answer and the three reasons for it.

4.26 Design a five-item pre-submission documentation checklist a practice could apply to every procedure note. Justify each item by naming the failure it prevents.

4.27 † Your practice's electronic health record auto-populates a complete review of systems on every note unless the provider actively clears it. Write the case for changing this configuration, addressed to a practice manager who will ask what it costs.

4.28 A coder tells you they code from the superbill checkbox rather than the note because "the note always matches anyway." Give the three-part response, including the specific statutory concept from Chapter 1 §1.4 that applies.

E. Certification-style questions

4.29 † A code may be assigned when:

• A. the coder is confident from clinical knowledge that the service occurred
• B. the documentation supports it without inference about what the provider meant
• C. the provider verbally confirms it
• D. the order for the service is present

4.30 An entry documenting a service that occurred earlier but was never recorded, made now and identified as such, is:

• A. an amendment
• B. an addendum
• C. a late entry
• D. a signature attestation

4.31 † A signature attestation statement may be used to:

• A. supply a missing signature on an order
• B. add clinical content omitted from a note
• C. identify the author of an otherwise unsigned entry
• D. replace an illegible note

4.32 Which of the following is a leading query?

• A. One that presents clinical indicators and offers several clinically reasonable options
• B. One that states the financial consequence of the response
• C. One that includes "clinically undetermined" as an option
• D. One that is documented and retained in the record

4.33 † In the outpatient setting, a diagnosis documented as "probable" or "suspected" should be:

• A. coded as if confirmed
• B. not coded; code the signs, symptoms, or reason for the encounter instead
• C. queried in every case
• D. coded with an unspecified code for that condition

4.34 The single most important section of an office note for assigning diagnosis codes is the:

• A. chief complaint
• B. history of present illness
• C. assessment
• D. review of systems

F. Write it

4.35 † Write the 100-word explanation a coder gives a newly hired colleague, who is a former nurse, about why clinical knowledge cannot supply what the note omits. It must be respectful of the colleague's expertise and unambiguous about the rule.

4.36 Draft the two-paragraph section of a practice's compliance policy governing amendments and addenda.

4.37 Write the note-reading checklist from §4.10 as a card that fits on an index card.

G. The Encounter

4.38 † Using Figure 4.2, list every element the note documents that will be needed for coding, by claim line, and every element it does not. Do not assign codes.

4.39 The chapter identifies three gaps in Figure 4.2 and ranks them by cost. Defend or challenge the ranking. Which one would you have listed first, and why?

4.40 † The assessment for the knee says "no definitive diagnosis established today." Write the one-sentence addition to the assessment that would have closed the first gap identified in §4.10. Then state why a coder may not write it, and who may.

4.41 Figure 4.2's problem list carries chronic kidney disease, stage 3a. The chapter says to record the observation and not act on it. Construct the strongest argument for querying now, and then the stronger argument for not doing so.

4.42 Update your Encounter Workbook (Appendix C): transcribe the four assessment items, the procedure elements, and the three gaps. You will use this page in eight more chapters.