Coding Documentation

CCS · 60 questions

• The face sheet lists admission type as elective, but the history and physical describes an emergent transfer for acute abdomen. What should the coder do before final coding?
• An operative report documents a left-knee arthroscopy, while the consent and history and physical document the right knee. What is the coder’s correct next step?
• The ED physician documents acute bronchitis, but after study the attending’s discharge summary documents pneumonia as the inpatient diagnosis. How should the coder reconcile this for principal diagnosis selection?
• Two attending physicians document different heart failure types for the same inpatient stay—one specifies systolic heart failure and another documents unspecified heart failure. What should the coder do?
• Final pathology reports a malignancy, but a progress note at discharge still states “rule out malignancy” without an updated clinical diagnosis. What is the appropriate coding documentation action?
• Case management notes document transfer to a skilled nursing facility, but the discharge disposition on the abstract still shows home. What should the facility coder do first?
• The anesthesia record documents an open approach, but the surgeon’s operative note describes a laparoscopic approach for the same inpatient procedure. What is the coder’s best next step for ICD-10-PCS?
• Nursing documents an admission weight that yields one BMI, while the dietitian note lists a different weight and BMI on the same day, and the coder is considering obesity-related coding. What should the coder do?
• An outpatient order requests a CT of the abdomen, but the radiologist performs and documents a CT of the abdomen and pelvis. How should the facility coder proceed?
• The prenatal record lists one gestational age, but the delivery note documents a different gestational age for the same obstetric encounter. What should the coder do before finalizing OB codes that depend on gestation?
• After an inpatient trauma admission, the tertiary survey documents an injury that was not listed on the initial ED trauma survey. What is the coder’s correct approach?
• Registration shows inpatient status, but the physician order places the patient in outpatient observation. What must the facility coder resolve before applying coding guidelines?
• The operative report header lists a laparoscopic-only procedure, but the surgeon’s narrative documents conversion to an open approach. How should the coder resolve the approach for coding?
• The medication list shows an active anticoagulant, but the history and physical states the patient is not on anticoagulation. Why does this matter for facility coding?
• The discharge summary and a separate discharge face sheet list two different conditions as the principal diagnosis for the same inpatient stay. What should the coder do?
• The OR schedule lists cataract surgery on the right eye, but the ophthalmology note and consent confirm the left eye. What should the outpatient facility coder do before assigning laterality?
• The patient was admitted for chest pain. Cardiology documents demand ischemia, but the discharge diagnosis list still shows only chest pain with no conclusion from the workup. What should the coder recognize?
• Maternal conditions appear on the newborn’s problem list after copy-forward from the obstetric record, with no infant clinical support. What should the facility coder do?
• A consult documents “history of DVT,” while the attending’s problem list lists “acute DVT” during the same inpatient stay. What is the coder’s best action?
• Nursing and anesthesia document different procedure start and stop times for an outpatient time-based service. What should the coder do?
• The record documents a “decubitus ulcer” without a stage, and the coder is considering a stage 3 pressure ulcer code. What is the correct action?
• An outpatient lesion excision note omits lesion size, which is required to select the correct CPT excision code family. What should the coder do?
• An implant sticker is in the inpatient chart, but the surgeon never documents the device in the operative report. The coder needs a PCS device character. What is the best next step?
• A nutrition note suggests severe protein-calorie malnutrition, but the provider has not diagnosed malnutrition. The coder is considering an MCC. What is required?
• A fracture diagnosis needs a seventh character for encounter type, but the record is unclear whether this is the initial or a subsequent encounter. What should the coder do?
• A dietitian documents a BMI value, but the provider never documents overweight or obesity. How should the facility coder handle BMI-related coding?
• A procedure begins laparoscopically and may have been converted to open, but the operative note does not clearly document conversion. What must the coder ensure before selecting approach?
• The provider documents “respiratory failure” without specifying acute or chronic. What should the coder do regarding acuity?
• An inpatient who had a biopsy is discharged, but the pathology report is not yet on the chart and pathology findings would change the diagnosis or procedure coding. What is the appropriate coding response?
• An outpatient note documents only “joint injection” without naming the substance injected. What should the coder do for accurate procedure and drug coding?
• A hospital inpatient coder finds a case-management note describing housing instability, but the attending progress notes and discharge summary never mention social determinants. Per current ICD-10-CM guidance on reporting SDOH Z codes, what should the coder do?
• Before assigning time-based mechanical ventilation codes for an inpatient stay, what documentation must the hospital coder confirm is in the health record?
• An ED provider documents 'otitis media' without specifying right, left, or bilateral, and the ICD-10-CM index leads to laterality-specific codes. What is the correct coding action?
• Blood cultures grow Escherichia coli, and the provider documents 'urosepsis' and 'UTI' but never links the organism to the infection. For combination coding of the infection with the organism, what should the hospital coder do?
• An operative report title says 'total colectomy,' but the body describes resection of only the ascending and transverse colon with anastomosis, and the extent is ambiguous. What should the inpatient coder do before selecting the ICD-10-PCS body-part/root detail?
• For hospital outpatient infusion coding under CPT hierarchy rules, what documentation must be present before selecting initial, sequential, and concurrent infusion/injection codes?
• An ECG shows ST elevation, but the attending documents only 'MI' without type, and episode-of-care detail needed for ICD-10-CM acuity coding is missing. What is the appropriate next step for the hospital coder?
• An inpatient is admitted for a reportable injury, and the record describes the fracture but omits how the injury occurred. What should the facility coder recognize about external-cause documentation?
• Facility policy and applicable coding guidance require provider documentation to support Glasgow Coma Scale reporting, but only nursing flowsheet GCS values are present. What should the coder do?
• A hospital policy requires an authenticated discharge summary before final bill drop. The summary is present but unsigned and incomplete. How should the coder treat this for final coding?
• Computer-assisted coding (CAC) soft-suggests a secondary diagnosis that does not appear in any provider documentation. What is the hospital coder's correct validation step?
• On hospital day 10, the problem list still shows 'active pneumonia,' but imaging has cleared, antibiotics have been stopped, and current notes describe resolved pneumonia. What should the coder do when validating documentation?
• Documentation mixes 'history of CHF' in one note with ongoing IV diuretics and daily assessments for acute decompensated heart failure during the stay. What validation question should the hospital coder resolve?
• A chest CT impression lists a pulmonary nodule that was auto-imported into the diagnosis list without provider acknowledgment or evaluation plan. What should the coder do before reporting it?
• The operative note objective and findings describe incision and drainage of an abscess with evacuation of purulent material, but CAC suggests an excision root operation. What is the correct validation action?
• To validate present-on-admission (POA) status for a secondary diagnosis, what chronological comparison should the hospital coder make?
• A secondary diagnosis of diabetes is listed, and the coder reviews the medication administration record (MAR) showing scheduled insulin during the stay. How does this documentation validation support reporting?
• A concurrent query for acute respiratory failure is outstanding with no authenticated provider response. What should the coder do regarding that diagnosis?
• At final coding, working diagnoses in the encoder differ from the attending's authenticated final diagnostic statement. What validation step is required?
• Before coding inpatient transfusion procedures or reporting transfusion-related detail that depends on quantity, what must the coder validate?
• An outpatient hospital procedure is canceled after anesthesia consent but before incision, yet the EHR charge router still posts the case as performed. What should the coder validate?
• A coder considers assigning a socioeconomic SDOH Z code based solely on census poverty data for the patient's ZIP code, with no related documentation in the record. What is the correct validation decision?
• A pathology report showing malignancy appears in the chart, but the accession identifiers do not clearly match the patient under coding review. What must the coder do before coding the cancer?
• Before assigning OB codes that depend on specific gestational weeks, what should the hospital coder validate in the record?
• ED triage notes list 'sepsis,' but the attending later documents that sepsis is ruled out and retracts the early impression, with no ongoing sepsis treatment criteria. What should the coder do?
• An inpatient coder is coding pacemaker generator replacement. The operative note describes removing the old generator and placing a new one, but the implant log line for the explanted serial number is blank. What should the coder do before finalizing device procedure coding?
• Utilization review notes early observation hours, but the attending later writes a clear inpatient admission order and the discharge summary reflects inpatient status. When validating the documentation trail for coding, what should guide which guideline set the coder applies?
• A procedure note states “wound debridement performed” without naming tissue depth. Wound photos show possible deeper involvement, and nursing notes mention packing. Before selecting a depth-dependent debridement code, what is the correct validation step?
• The medication list shows long-term warfarin, and a progress note mentions “hypercoagulable state.” Lab history shows prior DVT. Before assigning a secondary hypercoagulable-state diagnosis versus a long-term anticoagulant-use code, what should the inpatient coder validate?
• A coder is ready to lock an inpatient surgical case for final bill, but the authenticated operative report is missing and hospital incomplete-record policy requires it before final coding. What is the appropriate validation action?