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TRUE/FALSE
All diagnoses must be stated or confirmed by the physician and supported by the
documentation in the medical record. - ANSWERSTrue
Who has the responsibility of determining the diagnoses, sequencing them, and
assigning the symptom control rating? - ANSWERSIt is the responsibility of the clinician
in conjunction with the physician
Any changes to the OASIS assessment, including the diagnoses, must be approved by
the? - ANSWERSAssessing clinician.
If a diagnosis error has occurred how must it be corrected and what must be cancelled
and re-submitted? - ANSWERSThe error must be corrected on the POC and OASIS
and resent tothe physician for signature. The OASIS must be re-submitted, and the
RAP must be cancelled and re-submitted with the correct code (s)
This is used as a placeholder at certain codes to allow for future expansion -
ANSWERSLetter "X"
TRUE/FALSE
Homcare typically codes subsequent encounters - ANSWERSTrue, However there are
exceptions when it is coded as "initial" treatment
When the patient is receiving "active treatment" what is the 7nth character? -
ANSWERS"A" initial treatment
Examples of active treatment include? - ANSWERSSurgical treatment, emergency
department encounter, and evaluation and continuing treatment by the same or different
physician, Antibiotic therapy for post op infection, Wound vac treatment of wound
dishescence
NOS - ANSWERS"not otherwise specified" used when the medical record is insufficient
to assign a more specific code. What takes precedence over the guidelines? -
ANSWERSInstructions and conventions of the classification
What is the hierarchy of importance over the guidelines? - ANSWERSConventions and
Tabular instructions
Chapter-specific Guidelines
General coding Guidelines