Medical Records
Past surgical history is considered a component of which section of the note?
A. Problem List
B. Past Medical History
C. Review of Systems
D. None of the Above
"B - Past Medical History"
"A complete medical history includes a more in-depth inquiry into the patient's medical issues which includes all diseases and illnesses currently being treated, and those which have had any residual effects on the patient's health. A surgical history to include all invasive procedures the patient has undergone. Family history is another aspect of the patient's medical history with potential indicators of genetic predisposition to disease. Social history is a broad category of the patient's medical history but may include the patients smoking or othe " https://www.ncbi.nlm.nih.gov/books/NBK534249/
From the below scenario, would we code both F32A and F39
Assessment:
Depression:
Mood Disorder:
Code only F32A
Rationale: Common Language Description of F39 - "Mood disorder which does not meet the criteria for other mood disorders (e.g. persistent mood disorder, dysthymic disorder). "
Index Disorder - Mood - Depressive takes you to F32.A.
Always code the highest supported specificity in the note.
If there are multiple stages of CKD documented in the PMH or PL and not documented in a current portion of the note, the coder will default to the...
A. Highest Stage
B. Lowest Stage
C. Unspecified Stage
B - Lowest stage
Ciox Best Practices p8
Integumentary (Skin)
Which of the following is a name brand for the drug Metoprolol?
A. Imdur
B. Lopressor
C. Trandate
D. Sotalol
B - Lopressor
The section of the note where the provider documents their observations and findings during the examination
Physical Exam
Can anything be coded from the below sentence?
The patient's symptoms are consistent with major depressive disorder.
No, "consistent with" is unconfirmed verbiage
If Type I Diabetes and Insulin are both documented in the note, can we code both?
p14 Ciox Best Practice:
Yes, when the provider has clearly documented type 1 diabetes and long-term use of insulin, both codes can be captured.
Which bone in the human body is also known as the "kneecap"?
PATELLA
All of the following drugs can be used to treat hyperlipidemia except:
A. Lipitor
B. Zetia
C. Tricor
D. Lipozene
D. Lipozene
One of the following provider types is not valid for risk adjustment.
A. CNS
B. FNP-C
C. RD
D. SLP
"C- RD (Registered Dietician)
Can anything be coded from the snip below? Why or why not?
The patient is here for Alzheimer's disease. Has been on donepezil and finds it helpful. While some memory issues have been reported by the patient and their family, there seems to be a degree of uncertainty regarding the diagnosis of Alzheimer's as no records are available from previous clinician.
Do not code.
This is unconfirmed.
Can we use the ordering of a lab to support a condition?
Impression:
Hyperlipidemia
Diabetes
Orders:
Lipid Panel
A1C
Summary:
The presence of a lab (I.e., lipid panel) in lab orders should not be used as support for a condition unless there is an interpretation of the labs by the provider.
p17 Ciox Best Practice:
Provider must make a linkage to the lab in order to use the lab as support for the condition.
What is the suffix that denotes "surgical removal of a specified body part?"
-ectomy
Insulin, Testosterone, and Heparin can all be given via _________
Injection
SubQ/IM/IV
When *only* insulin needles (and not insulin) are present in the medication list and patient is on another type of medication that can be injected, do not capture Z794.
One of the following note types is not valid for RA.
A. Fine needle aspiration biposy
B. Colonoscopy
C. Lumbar Puncture
D. MRI
"D- MRI"
What (if anything) would we code from this note?
"Video chatted with patient's daughter as patient was sleeping in the next room. Patient has recently had some issues with her diabetes. Her blood glucose has been out of control. Did not visualize patient."
Do not code from this. The provider met with the patient's daughter and not the patient. The provider needs to have an encounter with the patient.
If the project guidelines contradict something in Ciox Best Practices, which guidance should we follow?
Project guidelines should be prioritized over Ciox Best Practices guidance. This guidance is used in the absence of project-specific guidance.
Question: What term describes the spread of cancer from one part of the body to another?
metastasis
Med List: Sildenafil (Pulm. HTN)
PL: Hypertension, Erectile Dysfunction, Hyperlipidemia
No.
Sildenafil is commonly listed as "for pulmonary hypertension" when no pulmonary hypertension exists in the note. In this case, it could also treat HTN and ED.
Ciox Best Practices p14
Ciox Best Practice:
No. Only code the condition if documented elsewhere in the note.
Rationale:
Due to copy and paste, and different ways lists are shown in EMRs, Ciox best practice is to code conditions documented inside the medication list only if document in another portion of the note.
Only one of the following is valid for Risk Adjustment.
A. Ambulance Records
B. Outpatient Surgery H&P
C. Hospice Care
D. Transitional Care Unit (Swing Bed)
"B- Outpatient Surgery H&P"
Can I50.9 be coded from the below?
"Tests show evidence of CHF"
Yes, "evidence of" is an example of confirmed verbiage.
What is the name of the site that houses our guidelines, newsletters, and Ciox Best Practices?
Coding Sharepoint
Name the medical term for the accumulation of excessive fluid in the body's tissues?
AND
Name ONE condition that can cause this.
Edema.
CHF
kidney disease
cirrhosis of the liver
venous insufficiency
chronic lung diseases
Which of the following medications are NOT a type of insulin?
A. Lantus
B. Humalog
C. Ozempic
D. Tresiba
C. Ozempic
Ozempic is classed as a GLP-1 receptor agonists and not insulin