A patient is seen in the obstetrical clinic, 6 weeks postpartum. She presents with resting heart rate of 58 BPM, initial blood pressure of 154/90, and respiratory rate of 20. She also complains of slight headaches, denies visual changes, and has no evidence of peripheral edema. History is significant for smoking and obesity. A blood pressure reading of 160/88 is taken at the end of the visit. The provider documents hypertension. Which of the following query opportunities is MOST appropriate?

• A. Association of hypertension to smoking
• B. Hypertensive crisis - unspecified
• C. A more specific diagnosis, such as pre-eclampsia or eclampsia
• D. Whether the hypertension was pre-existing or developed during pregnancy

A patient with stage 3 CKD presents to the clinic for evaluation. Upon review of labs, an elevated iPTH and a normal phosphorus level are noted. Which of the following diagnoses may be appropriately queried based upon these lab values?

• A. Secondary hyperparathyroidism of renal origin
• B. CKD stage 3 with hypoparathyroidism
• C. Hyperparathyroidism secondary to hypophosphatemia
• D. Primary hyperparathyroidism

A patient presents for a right inguinal herniorrhaphy in ambulatory surgery and is placed in observation status postoperatively. Provider documentation states: "Observation related to the post procedural urinary retention likely related to benign prostatic hyperplasia or adverse reaction to anesthesia." From this documentation, which of the following is the first-listed diagnosis?

• A. Adverse reaction to anesthetic
• B. Right inguinal hernia
• C. Benign prostatic hyperplasia
• D. Urinary retention

A CDI specialist is writing a query and including information from another facility's EHR via shared notes. Understanding that the ability to view shared notes may be revoked by the patient at any time, and to ensure HIPAA guidelines are followed, which of the following elements are BEST to include when sending the query?

• A. Location of shared note, date of shared note, provider name, and specific documentation
• B. Location of shared note, provider name, specific documentation, and any follow-up procedure
• C. Provider name, date of shared note, follow-up procedure, and date of review
• D. Provider name, date of shared note, specific documentation, and any follow-up procedure

Which coding guideline is primarily used to assign ICD-10-CM codes in outpatient settings?

• A. CPT Coding Guidelines
• B. Outpatient Coding Guidelines
• C. Uniform Hospital Discharge Data Set
• D. Inpatient Coding Guidelines