CCS EXAM PREP DOMAIN 2&3
QUESTIONS AND ANSWERS
Encounter - Correct Answers -Direct personal contact in the hospital between a patient
and a physician, or other person authorized by law to order or furnish services for
diagnosis or treatment of the patient. It does not include telephone contacts between a
patient and physician
Encounter examples - Correct Answers -A physician sees a patient in the hospital
A NP sees a patient in the family practice clinic
A physician goes to a nursing home to see a resident
A patient is seen by a PA in an OP clinic
A telemedicine visit between a provider in major city and a patient in small town
ICD-10-CM Coding Guideline
I.B.14 Documentation by Clinicians Other than the Patient's Provider
What is considered "clinicians other than the provider"? - Correct Answers --"clinicians"
other than the patient's provider refer to healthcare professionals permitted, based on
regulatory or accreditation requirements or internal hospital policies, to document in a
patient's official med record
ICD-10-CM Coding Guideline
I.B.14 Documentation by Clinicians Other than the Patient's Provider
The BMI, coma scale, NIHSS, blood alcohol level codes for social determinants of
health, and under immunization status should only be reported as a ___________. -
Correct Answers -The BMI, coma scale, NIHSS, blood alcohol level codes for social
determinants of health, and under immunization status should only be reported a
secondary diagnoses
ICD-10-CM Coding Guideline
I.B.14 Documentation by Clinicians Other than the Patient's Provider
If there is conflicting documentation from the same clinician or different clinicians, who
should be queried? - Correct Answers -If there is conflicting documentation from the
same clinician or different clinicians, the patient's attending provider should be queried.
, ICD-10-CM Coding Guideline
I.B.14 Documentation by Clinicians Other than the Patient's Provider
What exceptions does this guideline include? - Correct Answers -These exceptions
include codes for
BMI, depth of nonpressure, chronic ulcers, pressure ulcer stage, coma scale, NIH
stroke scale NIHSS, social detriments of health SDOH, laterality , blood alcohol level,
under immunization status
These are typically documented by other clinicians involved in the care of the patient.
the associated diagnosis must be documented by the patient's provider.
ICD-10-CM Coding Guideline
I.C.21.c.17 Social Determinants of Health SDOH
What are social determinants of health codes? - Correct Answers -Social determinants
of health codes describing social problems, conditions, or risk factors that influence a
patient's health should be assigned when this information is documented in the med rec.
Assign as many SDOH codes as are necessary to describe all of the social problems,
conditions or risk factors documented during the current episode of care
For example, a patient who lives alone may suffer an acute injury, temporarily impacting
their ability to perform routine activities of daily living
When documented as such, this would support assignment of code, Z60.2 problems
related to living alone. However, merely living alone, without documentation of a risk or
unmet need for assistance at home would not support assignment of code Z6 0.2.
High quality clinical documentation requirements - Correct Answers -Complete,
consistent, timely, clear, precise, legible, reliable
Query definition - Correct Answers -A communication tool or process, used to clarify
documentation in the health record for documentation integrity and accurate code
assignment for an individual encounter in any healthcare, setting
a query may be in a variety of formats: (3) - Correct Answers -electronic, written, verbal
When to query examples (11) - Correct Answers -Clinical indicators of a diagnosis, but
no documentation of the condition
Clinical evidence for a higher degree of specificity or severity
Uncertainty of a cause-and-effect relationship between two conditions or organisms
QUESTIONS AND ANSWERS
Encounter - Correct Answers -Direct personal contact in the hospital between a patient
and a physician, or other person authorized by law to order or furnish services for
diagnosis or treatment of the patient. It does not include telephone contacts between a
patient and physician
Encounter examples - Correct Answers -A physician sees a patient in the hospital
A NP sees a patient in the family practice clinic
A physician goes to a nursing home to see a resident
A patient is seen by a PA in an OP clinic
A telemedicine visit between a provider in major city and a patient in small town
ICD-10-CM Coding Guideline
I.B.14 Documentation by Clinicians Other than the Patient's Provider
What is considered "clinicians other than the provider"? - Correct Answers --"clinicians"
other than the patient's provider refer to healthcare professionals permitted, based on
regulatory or accreditation requirements or internal hospital policies, to document in a
patient's official med record
ICD-10-CM Coding Guideline
I.B.14 Documentation by Clinicians Other than the Patient's Provider
The BMI, coma scale, NIHSS, blood alcohol level codes for social determinants of
health, and under immunization status should only be reported as a ___________. -
Correct Answers -The BMI, coma scale, NIHSS, blood alcohol level codes for social
determinants of health, and under immunization status should only be reported a
secondary diagnoses
ICD-10-CM Coding Guideline
I.B.14 Documentation by Clinicians Other than the Patient's Provider
If there is conflicting documentation from the same clinician or different clinicians, who
should be queried? - Correct Answers -If there is conflicting documentation from the
same clinician or different clinicians, the patient's attending provider should be queried.
, ICD-10-CM Coding Guideline
I.B.14 Documentation by Clinicians Other than the Patient's Provider
What exceptions does this guideline include? - Correct Answers -These exceptions
include codes for
BMI, depth of nonpressure, chronic ulcers, pressure ulcer stage, coma scale, NIH
stroke scale NIHSS, social detriments of health SDOH, laterality , blood alcohol level,
under immunization status
These are typically documented by other clinicians involved in the care of the patient.
the associated diagnosis must be documented by the patient's provider.
ICD-10-CM Coding Guideline
I.C.21.c.17 Social Determinants of Health SDOH
What are social determinants of health codes? - Correct Answers -Social determinants
of health codes describing social problems, conditions, or risk factors that influence a
patient's health should be assigned when this information is documented in the med rec.
Assign as many SDOH codes as are necessary to describe all of the social problems,
conditions or risk factors documented during the current episode of care
For example, a patient who lives alone may suffer an acute injury, temporarily impacting
their ability to perform routine activities of daily living
When documented as such, this would support assignment of code, Z60.2 problems
related to living alone. However, merely living alone, without documentation of a risk or
unmet need for assistance at home would not support assignment of code Z6 0.2.
High quality clinical documentation requirements - Correct Answers -Complete,
consistent, timely, clear, precise, legible, reliable
Query definition - Correct Answers -A communication tool or process, used to clarify
documentation in the health record for documentation integrity and accurate code
assignment for an individual encounter in any healthcare, setting
a query may be in a variety of formats: (3) - Correct Answers -electronic, written, verbal
When to query examples (11) - Correct Answers -Clinical indicators of a diagnosis, but
no documentation of the condition
Clinical evidence for a higher degree of specificity or severity
Uncertainty of a cause-and-effect relationship between two conditions or organisms
