Chapter 4 — Quiz
Twenty-four questions. All documentation is constructed.
Multiple choice
1. The primary source of diagnosis codes in an office note is the:
- A. chief complaint
- B. review of systems
- C. assessment
- D. past medical history
2. A code may be assigned when the documentation supports it:
- A. in the coder's clinical judgment
- B. without inference about what the provider meant
- C. after a verbal confirmation from the provider
- D. if the order is present
3. A separately dated and signed entry adding new information, with the original entry intact, is a(n):
- A. amendment
- B. addendum
- C. late entry
- D. attestation
4. A signature attestation statement may not be used to:
- A. identify the author of an unsigned note
- B. supply a missing signature on an order
- C. authenticate an entry
- D. state that the author furnished the service
5. Cloned documentation is problematic primarily because it:
- A. is longer than necessary
- B. may document things that did not happen, obscures change, and creates a detectable pattern
- C. violates HIPAA
- D. cannot be electronically signed
6. In the outpatient setting, a diagnosis documented as "probable" is:
- A. coded as if confirmed
- B. not coded; code the signs, symptoms, or reason for the encounter
- C. always queried
- D. coded with the unspecified code for that condition
7. Which is a leading query?
- A. One presenting clinical indicators with several reasonable options
- B. One that names the financial consequence of the answer
- C. One offering "clinically undetermined"
- D. One retained in the record
8. The body of an operative report, rather than its heading, must be read because it may disclose:
- A. the surgeon's name
- B. conversion to an open procedure, additional procedures, and specimens taken
- C. the date of service
- D. the preoperative diagnosis
9. Since 2021, which is not a factor in selecting an office visit level?
- A. medical decision making
- B. total time on the date of the encounter
- C. review of systems
- D. risk of complications
10. The set of records used to make decisions about individuals, which patients may access under HIPAA, is the:
- A. legal health record
- B. designated record set
- C. audit trail
- D. superbill
11. A discharge summary alone is insufficient for inpatient coding because:
- A. it is not signed
- B. a condition documented in a progress note and omitted from the summary is still documented
- C. it does not contain diagnoses
- D. it is written by a resident
12. The correct response to discovering thin documentation while assembling records for an audit is to:
- A. have the provider add what they remember
- B. send what you have
- C. delay the response until documentation improves
- D. submit only the strongest charts
13. For a drug administered in the office, the documentation must include:
- A. the drug only
- B. the drug and route only
- C. the drug, the dose administered, the route, and any amount discarded
- D. the manufacturer
14. A patient's HPI states they "were told by another doctor" that they have a condition. The assessment does not mention it. You should:
- A. code the condition
- B. not code it — a patient's report of a prior diagnosis is not a provider's diagnosis
- C. code it as history
- D. query for permission to code it
15. In an electronic health record, an amended note's audit trail is:
- A. inaccessible after signing
- B. discoverable, and part of the record's story
- C. deleted after 30 days
- D. relevant only to IT
Short answer
16. State, in one sentence, what a code is a description of.
17. Name the seven steps of the note-reading method, in order.
18. Name the three kinds of inference the code-assignment rule forbids, with an example of each.
19. Give five circumstances that justify a query.
20. Explain why "read the assessment first, then read backward" is better practice than reading a note front to back.
21. (Chapter 1) A coder is told by a manager to select a higher level of service than the documentation supports. Name what the coder is and is not responsible for, and state what protects them.
22. A note documents a knee injection with no laterality stated anywhere. Write the compliant query in one or two sentences.
23. (Chapter 3) A diagnostic test claim is reviewed and the ordering provider's signed order cannot be produced. State the outcome and why clinical appropriateness does not save it.
24. Using Figure 4.2, name the four elements supporting modifier 25 and the section each is in.