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 DOCUMENTATION for
HEALTH RECORDS
Second Edition

Cheryl Gregg Fahrenholz, RHIA, CCS-P

Lead Author

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Lack of Healthcare Consumer Awareness. . . . . . . . . . . . . . . . . . . . 140

Cybersecurity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Components of the EHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Specialty-Based EHRs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Federal Policies Driving EHR Implementation. . . . . . . . . . . . . . . . . . . . 143
National Infrastructure for the EHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Providers and the Infrastructure for EHRs. . . . . . . . . . . . . . . . . . . . . . . 144
User Access. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Documentation Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Clinical Decision Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Data Dictionary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Designing an EHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Data and Information in an EHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Nonclinical Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Demographic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Financial Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Preliminary Clinical Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Consents and Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . 149
Documenting in the EHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Devices Used to Document in the EHR. . . . . . . . . . . . . . . . . . . . . . . . . 150
Regulating Health Record Content. . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Clinical Documents in the EHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Medical History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Report of Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Physician Orders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Outpatient Services Provided in Acute-Care Facilities. . . . . . . . . . . 154
Specialty-Care Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Discharge Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Autopsy Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Uses for Abstracted Electronic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
The Hybrid Health Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Health Record Storage Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
HIM Functions in an EHR Environment. . . . . . . . . . . . . . . . . . . . . . . . . 159
Authentication of EHR Entries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

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Guidelines to Prevent Fraud and Ensure EHR Documentation

Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Medical Identity Theft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Authorship Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Auditing Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Documentation Integrity: Automated Insertion of Clinical Data. . . 160
Corrections in Electronic and Clinical Documentation . . . . . . . . . . . . . 161
EHRs in Health Information Exchanges. . . . . . . . . . . . . . . . . . . . . . . . . 161
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Chapter 6 Clinical Documentation Improvement. . . . . . . . . . . . . . . . . . . . . 167
The Importance of Clinical Documentation . . . . . . . . . . . . . . . . . . . . . 168
Evidence-Based Documentation: The Theory of High-Quality
Clinical Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Seven Criteria for High-Quality Clinical Documentation. . . . . . . . . 169
Operational Considerations of the CDI Process. . . . . . . . . . . . . . . . . . . 174
The CDI Professional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Queries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Concurrent Query. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Retrospective Query . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Query Format. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
CDI and the EHR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Translating Clinical Documentation into Coded Data. . . . . . . . . . . . . . 185
How a Coding Professional Views an Inpatient Health Record . . . . 185
The Relationship between Clinical Documentation and Coding. . . 188
Clinical Documentation Analysis and Assessment. . . . . . . . . . . . . . . . . 191
Data Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Chapter 7 Information Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Quality and Safety of Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
The IG Principles and Examples for Each in Healthcare. . . . . . . . . . . . . 207
IG and Patient Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Clinical Documentation Improvement. . . . . . . . . . . . . . . . . . . . . . 208
Meaningful Use Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Coding and Quality Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Learning Health System and Quality Improvement . . . . . . . . . . . . 210

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The Role of HIM in Information Governance . . . . . . . . . . . . . . . . . . . . 212

Adaptive Leadership and IG. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Examples of IG Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Chapter 8 Data Analytics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Tools Used in Data Analytics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Microsoft Excel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Tableau. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Qlik View. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
R Studio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Public Data Web Sources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
National Initiatives on Big Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Concepts of Database Management . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Data Analytics and the Electronic Health Record . . . . . . . . . . . . . . . . . 229
Tools and Best Practices When Conducting Research in an
EHR Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Clinical Care, Data Analytics, and the EHR . . . . . . . . . . . . . . . . . . . . . . 230
Quality and Population Health and the EHR . . . . . . . . . . . . . . . . . . . . 231
Data Governance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

Part III Organization and Management of the Health Record . . . . . . . 239

Chapter 9 Federal and State Requirements and Accreditation
Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Federal and State Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
Federal Healthcare Statutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
HIPAA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
HITECH Act. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Federal Patient Safety Legislation. . . . . . . . . . . . . . . . . . . . . . . . . . 248
CMS Regulations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Medicare Conditions of Participation. . . . . . . . . . . . . . . . . . . . . . . 250
Medicare Compliance Surveys. . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Telehealth Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
CMS Quality Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Patient Satisfaction as a Quality Measure. . . . . . . . . . . . . . . . . . . . 254
Quality Improvement Organizations . . . . . . . . . . . . . . . . . . . . . . . 256

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Healthcare Corporate Compliance. . . . . . . . . . . . . . . . . . . . . . . . . . . . 256

Office of Inspector General and OIG Work Plan. . . . . . . . . . . . . . . 257
Recovery Audit Contractors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Federal and State Protection of Sensitive Health Information . . . . . . . . 259
Substance Abuse Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Behavioral Health Records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
HIV/AIDS Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Genetic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
State Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Licensure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Medicaid Eligibility and Administration. . . . . . . . . . . . . . . . . . . . . 261
Medicaid Compliance Programs . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Accreditation Requirements for Acute-Care Hospitals. . . . . . . . . . . . . . 262
The Joint Commission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Healthcare Facilities Accreditation Program. . . . . . . . . . . . . . . . . . 266
DNV GL Healthcare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Center for Improvement in Healthcare Quality . . . . . . . . . . . . . . . 267
Internal Hospital Policies and Procedures. . . . . . . . . . . . . . . . . . . . . . . 268
HIM Policies and Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Medical Staff Bylaws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Medical Records Committee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
Chapter 10 Ambulatory Care Documentation, Accreditation, Liability,
and Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Ambulatory Surgical Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Community Health Centers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Private Practice Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Diagnostic Imaging Centers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Missing Clinical Information in Outpatient Services . . . . . . . . . . . . . . . 279
Ambulatory EHR versus Hospital EHR. . . . . . . . . . . . . . . . . . . . . . . . . . 280
MU Criteria for Eligible Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . 283
MU for Eligible Providers by Stages. . . . . . . . . . . . . . . . . . . . . . . . 283
Credentialing and Licensure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
State and Federal Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
Governmental Regulations of Ambulatory Care. . . . . . . . . . . . . . . 286

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State Governments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

Ambulatory Care Accreditation Standards . . . . . . . . . . . . . . . . . . . . . . 289
Types of Ambulatory Accreditation Organizations . . . . . . . . . . . . . . . . 290
The Joint Commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Accreditation Association for Health Care . . . . . . . . . . . . . . . . . . . 291
The Accreditation Association for Ambulatory Health Care . . . . . . 291
Association for American Accreditation of Ambulatory Surgery
Facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
American College of Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Commission on Accreditation of Rehabilitation Facilities . . . . . . . . 292
Community Health Accreditation Partner . . . . . . . . . . . . . . . . . . . 292
The College of American Pathologists . . . . . . . . . . . . . . . . . . . . . . 292
Commission on Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
National Committee for Quality Assurance . . . . . . . . . . . . . . . . . . 292
Role of the Patient’s Primary Care Physician and the Maintenance of
Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Document Management and Imaging System. . . . . . . . . . . . . . . . . . . 294
Type of Document Imaging Scanners . . . . . . . . . . . . . . . . . . . . . . 294
Documenting Imaging Best Practices . . . . . . . . . . . . . . . . . . . . . . 295
Risk Management and Liability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Chapter 11 Long-Term Care Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Long-Term Acute-Care Hospital Settings . . . . . . . . . . . . . . . . . . . . . . . 304
Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Federal Regulations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
State Regulations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Accreditation Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Components of the LTCH Prospective Payment System. . . . . . . . . 307
LTCH Health Record Content. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
History, Physical, and Referral Information. . . . . . . . . . . . . . . . . . . 308
Principal Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
Admission Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Physician Orders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Progress Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Problem Lists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

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Consultation Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

Reevaluations and Assessments. . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Advance Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Laboratory Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Specialty Reports. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Flow Sheets. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Graphical Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Care Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Procedure Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Miscellaneous Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Medication Administration Records. . . . . . . . . . . . . . . . . . . . . . . . 313
Discharge Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
LTCH Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
LTCH PPS Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Chapter 12 Facility-Based Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Skilled Nursing Facility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
SNF Health Record Content. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
Resident Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Resident Assessment Protocols. . . . . . . . . . . . . . . . . . . . . . . . . . . 328
Other Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
SNF Accreditation Standards and Regulations . . . . . . . . . . . . . . . . . . . 334
Medical Necessity and Medicare Documentation . . . . . . . . . . . . . 335
Physician Certification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Standards Governing Assessments. . . . . . . . . . . . . . . . . . . . . . . . . 335
Medicare Quality Indicators for SNFs. . . . . . . . . . . . . . . . . . . . . . . 336
Risk Management and Liability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
Real-World Case Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
Chapter 13 Home Care and Hospice Documentation, Liability,
and Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Home Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
What Is Medicare-Certified Home Health? . . . . . . . . . . . . . . . . . . . . . . 343
Certified Hospice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344

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 xiv Detailed Table of Contents

Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
Home Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Home Health Payment Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Standard Core Assessment Tool—OASIS . . . . . . . . . . . . . . . . . . . . 345
Hospice Conditions of Participation. . . . . . . . . . . . . . . . . . . . . . . . 345
Hospice Core Assessment Tool—HIS . . . . . . . . . . . . . . . . . . . . . . . 346
Increasingly Complex Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . 346
Government Influences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
Office of Inspector General Oversight . . . . . . . . . . . . . . . . . . . . . . 347
Comprehensive Error Rate Testing (CERT). . . . . . . . . . . . . . . . . . . 348
The Medicare Home Care Benefit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
Documentation of Eligibility of the Provider . . . . . . . . . . . . . . . . . 349
Home Health under the Care of a Physician. . . . . . . . . . . . . . . . . . 349
Home Confinement (Homebound Status). . . . . . . . . . . . . . . . . . . 350
Skilled Services Requirement for Benefit Eligibility . . . . . . . . . . . . . 351
First Visit Criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
Intermittent or Part-Time Nursing. . . . . . . . . . . . . . . . . . . . . . . . . 352
Home Health Prospective Payment System . . . . . . . . . . . . . . . . . . 352
The Medicare Hospice Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
Provision of Care under the Medicare Hospice Benefit and
Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Payment System for Hospice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Home Health and Hospice Record Content . . . . . . . . . . . . . . . . . . . . . 358
Intake/Referral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
Home Care and Hospice Assessment Information. . . . . . . . . . . . . . . . . 361
Home Care and OASIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
Hospice and Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
Home Health Plans of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Hospice Plans of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Hospice Clinical and Progress Notes . . . . . . . . . . . . . . . . . . . . . . . 366
Home Health Clinical Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
Dietary and Nutritional Information . . . . . . . . . . . . . . . . . . . . . . . 367
Bereavement Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Progress Notes and the Discharge Transfer Record . . . . . . . . . . . . 367
Medicare Home Care Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368

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 Detailed Table of Contents xv

Quantitative Record Review Guidelines . . . . . . . . . . . . . . . . . . . . . . . . 370

Home Health Medical Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Medicare Hospice Surveys. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Home Health QAPI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Medical Review of Hospices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Medicare Hospice Quality Assessment Performance
Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Physician’s Documentation Review . . . . . . . . . . . . . . . . . . . . . . . . 375
Home Care and Hospice Legal Issues. . . . . . . . . . . . . . . . . . . . . . . . . . 376
Patient’s Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
Patient Self-Determination Act of 1990. . . . . . . . . . . . . . . . . . . . . 377
Do-Not-Resuscitate Orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Home Health Quality Initiative. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
Patient Outcome Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
Accreditation Quality Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . 382
CHAP Performance Improvement Standards. . . . . . . . . . . . . . . . . 383
The Joint Commission Performance Improvement Standards. . . . . 383
General Requirements of Documentation. . . . . . . . . . . . . . . . . . . . . . . 383
Communication and Timeliness of Documentation. . . . . . . . . . . . 383
Consistent and Complete Documentation. . . . . . . . . . . . . . . . . . . 384
Development of Documentation Policies and Procedures . . . . . . . 384
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
Chapter 14 Exploring Other Healthcare Settings. . . . . . . . . . . . . . . . . . . . . . 391
Regulations Common to All Healthcare Providers. . . . . . . . . . . . . . . . . 392
Outpatient Private Practitioners or Solo Practitioners. . . . . . . . . . . 393
Outpatient Ambulatory Integrated Clinical Settings. . . . . . . . . . . . 409
Government Healthcare Settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
Veterans Health Administration. . . . . . . . . . . . . . . . . . . . . . . . . . . 419
Other Military Healthcare Systems. . . . . . . . . . . . . . . . . . . . . . . . . 420
Correctional Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
Indian Health Service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Other Healthcare Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
Blood Banks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422
Coordinated School Health Programs . . . . . . . . . . . . . . . . . . . . . . 423
University-Based Student Health Services. . . . . . . . . . . . . . . . . . . . 424

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Veterinary Practices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424

Critical Access Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
A Note on Health Plans and Insurers . . . . . . . . . . . . . . . . . . . . . . . . . . 428
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469

Online Appendices

Available at http://www.ahimapress.org/fahrenholz5542/.

Appendix 3A Sample Consent Form

Appendix 3B EHRs Serving as the Business and Legal Records of Healthcare
Organizations
Appendix 3C Individual Access to Medical Records: 50 State Comparison
Appendix 4A NCVHS Measurement Framework for Community Health and
Well-Being, Vol. 4
Appendix 5A Paper-Based Health Record Forms
Appendix 11A Long Term Care Hospital Prospective Payment System
Appendix 14A Medical Record Retention Required of Health Care Providers: 50 State
Comparison
Appendix 14B Commission on Cancer’s Standard Manual Name Change

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 About the Lead Author

Cheryl Gregg Fahrenholz, RHIA, CCS-P, is the president of Preferred Healthcare Solutions,
LLC, and has more than 30 years of experience working with healthcare facilities, physicians, and
their staff. Her consulting services include revenue cycle integrity management, ICD-10 impact
analysis, multispecialty audits related to documentation and coding, Charge Description Master
(CDM) reviews, Clinical Documentation Improvement (CDI) audits, operational and financial
assessments, coding sessions for physicians and staff, charge capture and charge process redesign,
denial audits, risk and sanction analysis, compliance plan evaluations, electronic health record
selection and implementation, forensic auditing and litigation support, expert testimony, along
with interim or retainer professional support and customized project work.
Before establishing her own consulting firm in 1998, Gregg Fahrenholz served as the direc-
tor of Documentation, Coding and Reimbursement at the Primary Care Networks of Premier
Health Network and as the manager of Information Management at Miami Valley Hospital. Gregg
Fahrenholz holds a bachelor of science in health information management (HIM) from Bowling
Green State University and is an AHIMA-approved ICD-10 trainer.
Gregg Fahrenholz is a nationally recognized speaker on the topics of revenue cycle, documenta-
tion, coding, and compliance. She has published extensively at the national level through books and
peer-reviewed articles on revenue cycle integrity, documentation, and coding. She has co-chaired
AHIMA’s Practice Councils for both the Clinical Coding and Terminology and Physician Practice.
She served on AHIMA’s Nominating Committee and Annual Meeting Planning Committee among
other volunteer opportunities at AHIMA. She served for numerous years on the Ohio Health
Information Management Association board of directors. She received the Triumph Discovery
Award from AHIMA and the Distinguished Member Award from the Ohio Health Information
Management Association and the Miami Valley Health Information Management Association.

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 About the Chapter Contributors

Dilhari R. DeAlmeida, PhD, RHIA, is an assistant professor in the department of Health

Information Management at the University of Pittsburgh. She has a master’s degree in health
information systems and a doctoral degree focusing on documentation improvement in ICD-10.
In addition to her volunteer services for AHIMA, she teaches and advises both undergradu-
ate and graduate students in HIM. Dr. DeAlmeida has published on the topic of data analytics,
eResearch, and clinical decision support systems. She serves as a reviewer for Perspectives in
Health Information Management. Her research interests include electronic health record research
and data analytics in healthcare. She is also an AHIMA-approved ICD-10-CM/PCS trainer.

Thomas J. Hunt, PhD, RHIA, CHDA, FAHIMA, is an assistant professor at Rutgers University
in the School of Health Professions Department of Health Informatics. He previously served as
associate dean and professor of Health Information Management at Davenport University. Before
transitioning to higher education, he was successful in leadership roles with Sparrow Health
System, ProMedica Health System, and Mercy Health Partners. He is a past president of the
Michigan Health Information Management Association (MHIMA) and is also a past president of
the Lake Huron Michigan Health Information Management Association. Dr. Hunt earned a doctor
of philosophy degree in Global Leadership with a concentration in Organizational Management
from Indiana Institute of Technology, a master of business administration from Davenport
University, and undergraduate degrees from Cleary University and Mercy College of Ohio. He has
been a presenter at the International Federation of Health Information Management Associations
(IFHIMA) Congress and General Assembly, AHIMA Convention and Exhibit, AHIMA Assembly
on Education, as well as the MHIMA Annual State Conference.

Ella L. James, MS, RHIT, CPHQ, is the former director of corporate health information man-
agement and health information privacy officer at Hospital for Special Care in New Britain,
Connecticut. Currently, James is an independent ICD-10-CM coding consultant and auditor for
long-term care hospitals across the nation (LTCHs). James is past president of and twice sat on the
board of directors for the Connecticut HIMA and was an AHIMA Community of Practice (CoP)
facilitator for long-term care. She chaired the coding committee for the National Association of
Long Term Hospitals (NALTH). James has presented programs on HIPAA at the state, regional,
and national levels and has presented educational programs for coders and physicians on long-
term acute-care coding for NALTH. She has consulted on coding and documentation issues for
many long-term acute-care hospitals through NALTH. She is the author of Documentation and
Reimbursement for Long-Term Care and contributing author of the AHIMA publication Health
Information Management Compliance and Documentation for Health Records.

Neisa Jenkins, EdD, RHIA, earned her bachelor of arts degree in Health Information Management
at the University of Illinois (Chicago), a master of arts in Health Information Management at the
College of St. Scholastica and her Doctorate of Education at Walden University. She has over 25
years of experience in Health Information Management. Her professional background includes

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 xx About the Chapter Contributors

HEDIS auditing, consulting, quality improvement, utilization management, release of information,

EHR-S implementation, HIPAA implementation, ICD-10-CM/PCS, and teaching in higher edu-
cation. Dr. Jenkins has taught courses in health information management, health service manage-
ment, and healthcare administration. She has held positions as program dean, faculty chair, visiting
professor, and full professor. Dr. Jenkins’s teaching philosophy is borrowed from Martin Luther
King Jr.: “Intelligence plus character—that is the goal of true education” (Martin Luther King Jr.
“The Purpose of Education.” 1947).

Suzanne Paone, MBA, DHA, RHIA, is an accomplished healthcare executive in academic med-
icine including awards by the American Hospital Association and Microsoft. She transverses aca-
demics with 12 years of teaching and curriculum development in analytics, HIM, informatics,
and strategy. She speaks to and advises education, healthcare, and technology companies. Current
research includes Transformational Analytics curricula development. Full-time appointment is at
Ashford University in HIM and dual appointments include: University of Pittsburgh HIM, Pitt
Graduate School of Public Health MHA, and the MBA program at Carlow University. She is the
president of Innovation Advising, a cooperative platform for professional services based in servant
leadership. Suzanne holds several not-for-profit board positions and is published in technology
adoption, eHealth, and health data analytics.

Laurie A. Rinehart-Thompson, JD, RHIA, CHP, FAHIMA, is the director of the health infor-
mation management and systems program and an associate professor at The Ohio State University.
She earned her bachelor of science and juris doctor degrees from The Ohio State University. Her
professional experiences span HIM education, behavioral health, home health, and acute care. She
has served as an expert witness, testifying regarding the privacy of health information. She has
chaired the AHIMA Professional Ethics Committee and has served on numerous AHIMA com-
mittees and the Ohio Health Information Management Association board of directors. She is a
coeditor and coauthor of AHIMA’s Fundamentals of Law for Health Informatics and Information
Management; author of AHIMA’s Introduction to Health Information Privacy and Security; and
a contributing author to numerous HIM textbooks and periodicals. She received the Ohio Health
Information Management Association’s Distinguished Member Award and the AHIMA Legacy
Award in 2010, and she became an AHIMA fellow in 2011.

Susan Rossiter, RHIA, CHPS, has over 30 years’ experience in a variety of settings within
the health information management field. Since 2003, she has been the Health Information
Management operations manager for the University of Texas Southwestern Medical Center, a large
academic medical center located in Dallas, Texas. Prior to that, she was the Hospital Compliance
officer for Terrell State Hospital and has several years of experience in management of HIM depart-
ments for acute care, behavioral health, and ambulatory care organizations. Rossiter graduated
with honors from Texas Woman’s University, where she received the Outstanding Senior Student
in the State award from the Texas Medical Record Association and the Dallas Outstanding Senior
Student award from Texas Woman’s University. In November 2000, she received a Certificate of
Recognition from the Governor’s Commission for Women as one of the Outstanding Women in
Texas Government. As chair for the Executive Women in Texas Government, Dallas Affiliate, she
supports and promotes women in leadership service to the state of Texas.

Lisa Selman-Holman JD, BSN, RN, HCS-D, COS-C, HCS-O, HCS-H, is the owner of Selman-
Holman & Associates, LLC. A 30-year veteran of home care as an RN and as an attorney, she has
participated in the writing of home care regulations and has been involved in accreditation surveys,

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 About the Chapter Contributors xxi

acquisitions, and many regulatory crises. Responsibilities have included risk management, sur-
vey compliance, Medicare appeals, Corrective Action Plans, due diligence audits, consulting with
agencies, and education of staff. Selman-Holman obtained her JD from University of Houston
and her BSN from the University of Tulsa. She is certified as a home care coder and a hospice
coder and is certified in OASIS. She is the chair of the Board of Medical Specialty Coding and
Compliance and an editor of the Decision Health coding manual. She has served on regulatory
task forces and the Quality Improvement Organization for OBQI. Current projects include online
programs through CodePro University and outsource coding through CoDR—Coding Done Right.
She is an AHIMA-approved ICD-10-CM trainer.

Valerie J. Watzlaf, PhD, MPH, RHIA, FAHIMA, is an associate professor in the Department
of Health Information Management (HIM) at the University of Pittsburgh. She has worked as a
HIM practitioner and consulted in several healthcare organizations in HIM, long-term care, and
epidemiology. Dr. Watzlaf has chaired and served on multiple AHIMA committees and boards
such as the Board of Directors of AHIMA and the AHIMA Foundation and chair of the Council for
Excellence in Education (CEE). Dr. Watzlaf was elected as president/chair-elect of AHIMA start-
ing in 2018. She has coauthored the textbook Health Informatics Research Methods: Principles
and Practice. Dr. Watzlaf is also on the editorial advisory board for the Journal of AHIMA and for
Perspectives in HIM. She has delivered over 100 presentations and authored over 50 publications
and is the recipient of numerous awards and professional accolades including the AHIMA Triumph
Award for Research, PHIMA’s Distinguished Member Award, and the University of Pittsburgh’s
SHRS Distinguished Alumnus Award.

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 Acknowledgments

Cheryl Gregg Fahrenholz wishes to thank Ashley Latta, production development editor, for her
detailed eye and continued guidance with this publication. Additionally, she thanks the contribut-
ing authors for sharing their expertise and time in order to produce a comprehensive publication
for HIM readers.
A special thanks from Cheryl to her husband, Mark, and mother, Pat, for their never-ending
support. With all of the challenges in our busy lives, they make it easier to balance professional
and family life in order for this publication journey to be a success.

AHIMA Press would like to acknowledge the following contributors for their work on prior
editions of this textbook.

Kathleen Munn, RHIA

Diana Warner, MA, RHIA, CHPS, FAHIMA
Margaret White, MS, NHA, RHIA, CPHQ

AHIMA Press would also like to thank Ruthann Russo, PhD, MPH, RHIT, for serving as a
volume editor in the prior edition of this text.
Finally, we would like to thank Kathleen M. Kirk, MS, RHIA, CHC, for her review and feed-
back on this text.

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Exploring the Variety of Random
Documents with Different Content
 CHAPTER XII.
Will the reader permit us to place him somewhere between earth
and sky two days after the events recorded in the last chapter had
occurred? From this exalted position, and provided, as he is, with
far-seeing eyes, he must observe, with more or less interest, that
the streets of Rexopolis, the capital of Rexania, are thronged with
crowds of people who move hither and thither with a restlessness
apparently due to constrained excitement that has not yet
crystallized into any set purpose. Around the palace, he will notice,
regiments of soldiers stand on guard, while, now and then, up or
down the avenues of the well-laid-out city dash squadrons of light
cavalry. The sight will suggest to him that Rexopolis, at the crisis at
which he views it, represents a microcosm in which all that is
characteristic of Old-World monarchies finds physical expression—a
restless and discontented people, an army half-hearted in its defence
of the palace and what that building represents, mystery and
misrepresentation and misery inside the king’s abode, and the wild
mutterings of protest and warning outside the sacred precincts of an
anachronistic cult.
But it strains the reader’s eyes to look so far afield. Back across
the wide blue expanse of the broad Atlantic his gaze returns, and
straight beneath him he sees various people who approach each
other slowly, ignorant of the strange fact that the impending
upheaval in a minor city of Europe is to have a marked influence
upon their respective lives.
Behold Ludovics, the restless victim of too much patriotism and
too little self-control, pausing in helpless hesitation outside the
gateway of a road-house not many miles above Harlem Bridge. The
afternoon has grown warm, and Ludovics has walked far and fast. Is
it strange that he craves a stimulant?
Look forward, farther eastward. If your eye has not grown weary,
you will observe that a youth and two women are seated on the
piazza of the Country Club, engaged in the harmless occupation of
discussing the adaptability of the weather and the roads to a spin on
their wheels. Unless our impressions are deceptive, the youth is Ned
Strong, and one of the women is his sister. You have not yet been
introduced to their companion, Mrs. Brevoort, but surely you have
heard of the beautiful widow who last season made herself famous
on two continents by refusing to turn over to an English peer her
fortune and her liberty. There are those who say that she was
sufficiently eccentric to love her husband and to mourn him dead,
but the impression has prevailed in the Westchester set of late that
what an English duke failed to accomplish Ned Strong bids fair to
compass.
Turning your gaze away from this attractive trio, after you have
noted, perhaps, that an air of melancholy seems to surround the tall,
lithe figure of Kate Strong, you will observe that Norman Benedict
has just left a New York train at the New Rochelle station, and that
his face bears an expression of suppressed excitement kept in check
by a set purpose that may at any moment encounter insuperable
obstacles. If you watch him a moment, you will see that he bargains
with the driver of a light, open carriage, and, after making terms,
enters the vehicle and is driven toward the Sound.
Has your eye grown weary? Surely Prince Carlo is worthy of a little
optic effort on your part. See him seated on the balcony of the
ramshackle old manor house, his cheek resting on his hand as he
gazes mournfully across the restless waves of the Sound and
wonders what passes in the palace at Rexopolis. Could he see, as we
have seen, the restless populace, the armed guards, the busy
cavalry, he would know that a crisis in the fate of his country is at
hand, and the look of settled melancholy on his handsome face
would change to an expression of mingled anger and despair. But
Prince Carlo is young, and youth inclines to hope. The beauty of the
scene that lies before him on this bracing autumnal afternoon is
conducive to an optimistic mood, and, in spite of the seemingly
desperate character of his position, the young man dreams rather of
love than war, and the smiling face of a fair-haired American girl
comes between him and the frowning countenance of red-scarred
revolution.
Perhaps Prince Carlo is undergoing a temptation different from
any that ever before assaulted a son of kings. It is possible that
under the influence of a caressing environment, lulling his senses by
the beauty of earth, and sea and sky and the gentle kisses of the
warm south wind, he thinks with a shudder of the horrors that
surround him in a palace far away, and longs for the peace that life
in a land where it would be “always afternoon” would bestow. What
if his father died and he, the crown prince, should never return to
Rexania? What if, taking to his heart a wife who would be his queen
in a kingdom where no traitors lurked, he should forever abandon
the cares and perils that had made his father’s existence one long
nightmare, to which death alone could bring relief? It might be that
the historians of his country would call him, in the years to come, a
traitor to the cause he had been born into the world to uphold, the
Judas Iscariot of age-end monarchy. But, for all that, his gain would
be peace and love.
Prince Carlo’s temptation was not a mere weighing of abstract
propositions, nor even the natural inclination of an imaginative youth
to take the flower-bedecked path of least resistance. There was an
influence at work to make him subservient to the wishes of the men
surrounding him that none of them suspected and that he himself
only vaguely realized. How great an impression the few hours he
had spent in Kate Strong’s companionship had made upon him he
was just beginning dimly to appreciate. He found himself practically
unable to compel his mind to dwell for any great length of time on
the weighty problems that were his to solve. He would discover, to
his dismay, that while mentally in search of a path that would lead
him in honor from the difficulties that beset him, his mind
obstinately refused to confine itself to his immediate environment
and all that was involved therein, and would devote itself to
reproducing for his delight the tones of a maiden’s voice, the gleam
of her eloquent eyes, the fascinations of her gestures and her
smiles.
 He upon whom rested the destinies of a nation—perhaps the
future of institutions hallowed by time and claiming a divine origin—
had become little more than a love-sick youth, gazing dreamily upon
the heaving bosom of a land-locked sea and longing for the
presence of the woman his young heart craved.
Thus beneath us have we seen a few of the countless millions
upon whom the September sun shone down that day; and we know
that in their comings and their goings they wove unconsciously that
web of destiny whose warp and woof fashion the garment that hides
the mystery of life.
 CHAPTER XIII.
“Woman in bicycle costume is an acquired taste,” Ned Strong had
once remarked to a friend. That was before Mrs. Brevoort had taken
to wheeling. She had converted him to a belief in the artistic
possibilities of a bifurcated dress for women. He had come to the
final conclusion that the desirability of a bicycle costume, so far as
the gentler sex is concerned, must remain wholly a local issue.
Experience was teaching him that generalizations regarding the
progressive woman of to-day are worthless. Furthermore, he had
learned that whether or not he admired their ways and costumes
made little difference to the women of his set. The iconoclastic
tendency of recent years finds no more striking illustration than in
the fact that women no longer sacrifice their comfort to their dress
for the sake of man’s approval, but dare to be unconventional for the
sake of their own comfort.
And Ned Strong was obliged to acknowledge to himself that Mrs.
Brevoort, dark, piquante, vivacious, presented an extremely
attractive picture on this September afternoon as she sat gazing at
the blue waters of the Sound, equipped for a long ride on her wheel.
That Kate Strong was a much more striking and impressive figure
than Mrs. Brevoort was a fact that had not appealed to the young
man’s mind. Perhaps he had not observed his sister critically. Or it
may be that he had so long taken it for granted that Kate always
made a good appearance that he was not inclined to waste time on
the question as to the adaptability of a bicycle costume to his sister’s
use. At all events, the youth found pleasure in confining his
attentions to Mrs. Brevoort, and failed to notice that his sister’s face
wore an expression of melancholy and that there was a listlessness
in her manner that the warmth of the day could not wholly explain.
“And you have heard nothing more about him?” asked Mrs.
Brevoort, gazing interestedly at Ned Strong. “It seems very strange
that he has never written you a line.”
 “Doesn’t it?” cried the young man. “And he was such a
thoroughbred in his manner and appearance! Wasn’t he, Kate?”
“He was very attractive,” answered his sister, somewhat
reluctantly, it seemed. “I feel sure that some day we shall find an
explanation to the mystery.”
“Oh, I don’t know,” exclaimed Mrs. Brevoort, airily. “You see, I
don’t take a bit of stock in these foreigners. I have seen so much of
them! It may be bad form on my part, but I prefer an American
gentleman to the most fascinating European that ever claimed
descent from Charlemagne or William the Conqueror.” She cast a
mischievous, challenging glance at Ned Strong, and went on:
“There’s something about monarchical countries that begets ideal
lovers but impossible husbands. The greatest complaint over
absentee landlords on the other side comes from American girls who
have married titled foreigners.”
Ned Strong laughed. “On behalf of my fellow-countrymen I thank
you, Mrs. Brevoort. It is too bad that your convictions have not a
greater following here among us.”
“So much the worse for those who do not agree with me. How
much can an American girl know about a titled foreigner who comes
over here looking for a rich wife? Take the case you have just been
telling me about,” continued Mrs. Brevoort, vivaciously. “This
fascinating youth called himself ‘Count Szalaki.’ How easy it was for
you to discover that there was no such title in Rexania! ’Twas
surprisingly clumsy on his part.”
“That’s one reason that leads me to think,” remarked Ned, “that
there is something more in the affair than a mere adventurer’s
escapade. If he had been a fraud he would have been more careful
in his choice of a name. If he was, as I have sometimes suspected, a
man very high in rank, who wished to disguise his identity, he would
have chosen a title that did not exist, taking it for granted that we
would respect his wish to remain unknown. There are royal
personages on the other side who travel under names that one
cannot find in Burke’s Peerage or the Almanach de Gotha.”
“That’s merely a matter of form,” exclaimed Mrs. Brevoort,
glancing at Kate. “Everybody knows who they are, wherever they go.
I was introduced to a king in Paris who had chosen to trot around
under the name of Mr. Smith, but it was a very thin disguise. He was
such a wretched conversationalist that I knew at once that he
concealed a throne behind his stupidity. A real Mr. Smith could have
talked about something besides the weather.”
Kate smiled at the sarcastic little woman’s words.
“What a thorough democrat you are, Mrs. Brevoort!” she
remarked. “I almost suspect that you intend to go in for politics.”
“Why not?” cried Mrs. Brevoort enthusiastically. “If we don’t take
part in public affairs, other women will. I believe it is our duty to
raise the tone of politics by taking an interest in them. If the men of
our class won’t do their duty by the State, it is for us to take their
place.” She looked at Ned Strong defiantly.
“I suspect,” he remarked, cautiously, “that you do not approve of
my indifference to public affairs, Mrs. Brevoort.”
“Most assuredly I do not,” she exclaimed emphatically. “A youth
who claims a divine right to occupy a European throne and defends
that assumed right with cannon and gunpowder is, to my mind, in a
false position, but he is more consistent than a young American who
possesses the prerogative of the ballot and won’t take the trouble to
go to the polls to vote.”
Ned Strong laughed merrily. “What a long memory you have, Mrs.
Brevoort! It is nearly a year since you learned that I failed to register
last fall, and now you bring a sweeping accusation against me. I fear
you do not find me possessed of the saving grace of patriotism.”
“Patriotism!” cried the youth’s accuser. “Surely, if you have it, it
finds queer ways of expression, Mr. Strong. You fail to vote, and yet
you are forever denouncing this country for going to the dogs. I
really believe that I have heard you crack a joke at the expense of
George Washington.”
A smile of amusement crossed Kate Strong’s face. “He deserves
what you are giving him, Mrs. Brevoort. Ned is a thorough believer
in his divine right to let other people save the country.”
“This is unfair,” cried the young man, with assumed annoyance. “I
am outnumbered two to one. You have me at a disadvantage. But I
will not attempt now, Mrs. Brevoort, to defend my position. And,
luckily for me, here comes my chance for escape. You cannot talk
politics on the wheel, you two. Are you ready to mount? It is just
three o’clock, and we are in good time for a long spin.”
A boy in livery had brought their wheels to the front of the club-
house, and, mounting quickly, the trio sped down the pathway
toward the entrance that opened on to the grounds from the main
highway. Mrs. Brevoort and Ned Strong led the way, and Kate
followed them, a flush of physical enjoyment mounting to her cheeks
as she chased the south wind inland.
 CHAPTER XIV.
Mrs. Brevoort and Ned Strong sped along in silence for a time.
The roads were dry and hard, and there was enough life in the
breeze that had kissed the sea to make even violent exercise
seductive. Ned’s companion was an enthusiastic and accomplished
wheelwoman, and she pedalled on merrily by his side, sometimes
smiling up at him in the mere joy of physical exertion. They had
reached the high-road, and were rapidly making their way toward
New Rochelle when Ned turned to his companion and said:
“Tell me, Mrs. Brevoort, what is your idea of Kate’s feeling toward
Count Szalaki? Do you think she is really interested in the man?”
“How stupid you are!” cried the little woman, who seldom failed to
display either real or assumed enthusiasm regarding any given topic
of conversation. Turning in her saddle, she looked back, and saw
that Kate Strong was wheeling steadily forward a hundred yards to
their rear. “But what else could I expect? All men are stupid about
certain matters. Of course your sister is interested in Count Szalaki.
So am I. I am wild to see the boy. From what you both say of him,
he must be simply irresistible.”
Ned Strong frowned and impatiently increased the speed of his
wheel. He knew how to withstand the coquetry of a young girl, but
the “in-and-out running of a widow,” as he called it to himself, kept
him in a state of nervous worry most of the time.
“I suppose,” he remarked crossly, “that what a man needs in these
days to make him interesting are black curly hair and an air of
mystery. In that case I’m out of it completely.”
Mrs. Brevoort laughed aloud.
“What a jealous creature you are, Mr. Strong! Your wife will have a
sad life of it, unless she is a very clever woman.”
 “I don’t intend to marry,” remarked the youth sternly. “What a fool
I’d be to sell my birthright for a mess of affectation! And that’s what
a woman is to-day—simply a mess of affectation.”
“What an elegant expression!” cried Mrs. Brevoort, a gleam of
malice in her laughing eyes as she looked up at the youth, who was
gazing stubbornly forward and pushing the pedals of his wheel as
though he had suffered a great wrong and was obliged to work for
his living. “But it does you credit, Mr. Strong. It indicates on your
part a remote but more or less intimate acquaintance with biblical
lore.”
“But there’s one thing certain,” continued the young man, not
heeding her sarcasm, “and that is that if I should marry I would not
tie myself down to a silly girl who might at any moment meet a
curly-haired man with a title and leave me in the lurch.”
Mrs. Brevoort laughed mockingly.
“How self-confident you are, little boy!” she exclaimed. “Let me tell
you, sir, it is my opinion that you will marry a blue-eyed, golden-
haired young doll, who will make you believe that you are the most
wonderful man on earth and that she is the happiest woman. I can
see it all in my mind’s eye. You prize your freedom, as you think,
more than most men. It is just your kind that fall victims to the
sweet-faced, blond-haired little vixens who make the most tyrannical
wives in the world. Do you like the prediction?”
The youth turned a frowning face to his vis-à-vis. “Why, oh, why,
Mrs. Brevoort,” he cried, “will you check the natural flow of my
spirits by so dire a prophecy? Think of the awful fate that awaits me,
if your words are true! I acknowledge that I have seen other men,
perhaps as hard to suit as I am myself, falling into the clutches of
spotless young girls who have lured them into the awful maelstrom
of marriage; but I swear to you that I shall profit by their
experience. I should never marry because I wanted a parlor
ornament. When I give up my liberty, I shall insist upon a quid pro
quo.”
 “What in the world is that, Mr. Strong?” cried Mrs. Brevoort,
looking shocked as she glanced up at him with exaggerated
amazement.
“That’s Latin,” answered the youth densely. “It’s a dead language,
but I used it for a very live purpose. I am not talking at random, you
know, Mrs. Brevoort. There is method in my madness.”
Ned Strong looked down at his companion meaningly, but she
refused to meet his gaze.
“But method never yet saved madness from disaster,” she
remarked, sagely.
Her words seemed to check the youth’s impetuosity, for he cast a
pleading glance at her averted face and then wheeled forward in
silence for a time.
“The fact is,” he began again, after he had renewed his courage,
“the fact is, Mrs. Brevoort, that you don’t understand me.”
A smile that he could not see from his exalted perch crossed the
widow’s face. It is only a very young man who ever dares to tell a
woman that she does not weigh him justly. The average man may
deceive other men; it takes a genius to blind a woman.
“Explain yourself,” she urged, not too warmly.
“I don’t want to give you the impression,” he went on, hesitatingly,
“you know, that I don’t admire women—that is, some women, don’t
you see?”
“I see,” she answered pitilessly; “you admire women—some
women, that is—for anything, everything, but matrimony. You said a
few moments ago that you would never marry.”
“Did I?” he asked, almost penitently. “I had forgotten that I went
so far. But, I assure you, I didn’t mean to imply, you know, that
under certain circumstances and—don’t you see—if I got the
promise of just the right woman, that I shouldn’t be very glad to
give up my freedom, don’t you know; that is, if it was perfectly
agreeable to her, of course.”
Mrs. Brevoort laughed outright, as they bowled down a long hill at
the top of which the Strongs’ manor-house peeped above the trees.
“You are the most amusing man I know, Mr. Strong,” she
exclaimed, as they reached the level road and moved forward more
slowly. “If you were more consistent, you wouldn’t be half so much
fun.”
The youth was not altogether pleased at her remark. He glanced
at her searchingly.
“You may do me an injustice, Mrs. Brevoort,” he said firmly. “It is
more than possible that I am more consistent than you suspect.”
“In what?” she asked, rather recklessly, looking up at him
mischievously. The expression in his eyes caused her a pang of
regret at the challenge she had made.
“In my ideas regarding matrimony, in my convictions as to the
woman I should wish to marry,” he answered, meaningly. “Shall I
explain?”
Mrs. Brevoort gave a questioning glance at his face and realized
that he must not explain. She turned in her saddle, as if seeking the
support of an ally at a crisis that must be averted at any cost.
“Why, where is Kate?” she cried, checking the speed of her wheel
and gazing back eagerly along the road and up the hill that crept
toward the manor-house.
Ned Strong turned, rather impatiently, and saw that the road was
deserted, save that half-way up the hill an open vehicle, that he and
Mrs. Brevoort had been too absorbed in conversation to notice when
it passed them, was slowly mounting toward the summit.
“We must go back and find her,” cried Mrs. Brevoort, dismounting
from her wheel and looking at Ned anxiously.
 “It would be useless,” he said, stubbornly. “She has grown tired of
riding alone and has gone back to the club-house. Or perhaps she
has stopped at the lodge to speak to Rudolph. That’s our old
homestead up there, you know, Mrs. Brevoort. Really, I don’t think it
would pay us to climb that hill on the remote chance of finding her.
We’ll turn off the main road just above here and get back to the
club-house at once if you wish. It’s a shorter cut than we could
make by retracing our road over the hill.”
Mrs. Brevoort reluctantly remounted her wheel.
“If you had not talked so much nonsense,” she remarked unjustly
to Ned Strong as they resumed their way, “we would not have lost
track of Kate.”
“A remark that I consider highly complimentary,” commented the
youth, smiling contentedly down at the disturbed countenance of
Mrs. Brevoort.
 CHAPTER XV.
Posadowski passed through Prince Carlo’s sleeping-room and
stepped out upon the balcony. The heir to a throne was still
dreaming of love and peace in a land where Cupid should reign
supreme, as the arch-conspirator joined him. The young man’s face
was pensive with the gentle longings that tinged his revery with
sadness. He turned toward Posadowski and said cordially:
“Be seated. I wish to talk with you.”
The clear gray eyes of the exiled Rexanian rested searchingly on
the pale, clean-cut face of the youth, and he smiled benignly as he
drew a chair toward his captive and, seating himself, awaited the
latter’s pleasure.
“How long have you lived in this country, Posadowski?” asked the
prince, abandoning his smiling visions with an effort and returning to
the dreary realities of life.
“Nearly ten years,” answered the revolutionist, whose gray hair
proved that he was older than his smooth pink and white complexion
would have indicated.
“I wish to ask you a few questions,” continued Prince Carlo. “I feel
—in spite of the fact that you deceived me at our first meeting—that
in the larger matters pertaining to the questions at issue between us
I can trust you implicitly. I give you credit, Posadowski, for being a
man of good intentions and honest in your avowed love for Rexania.”
The arch-conspirator bowed gratefully, in acknowledgment of the
generous words of the man he had wronged.
“Tell me frankly,” went on the prince, “do you find, Posadowski,
that in this land of democracy the people of the lower classes—for I
learn that there are class distinctions in America—are in better case
than the working-people of Rexania? Compare, for instance, the rich
and the poor in Rexopolis and the rich and the poor in New York. Is
there not more awful poverty in yonder city than in my capital across
the sea? Conversely, is there in Rexania a nobleman who wields over
the lives of others an authority as tyrannical as that exercised by the
great landlords of New York?”
Posadowski gazed at Prince Carlo in bewilderment. He had come
to point out to his royal captive the far-reaching influence his
abdication of a crown would have upon the oppressed millions of the
human race who still live and struggle and perish beneath the
crushing weight of thrones and what those thrones demand; and, lo,
this incarnation of obsolete systems and archaic theories had asked
him a few pertinent and practical questions that rendered
Posadowski’s present mission seemingly absurd. For the arch-
conspirator was a clear-headed, honest-hearted man, whose
constitutional detestation for shams had long ago made him a rebel
against monarchy, and now rendered him dumb as he slowly took in
the full significance of the line of inquiry Prince Carlo had put forth.
“You do not answer, Posadowski,” went on Prince Carlo, his voice
and manner growing sterner as his words flowed more freely. “Do
you know, man, why I came to this country, why I defied my father’s
wishes and ran a risk greater even than I imagined at the moment? I
wished to see for myself what popular government has really done
for a great people in a century of time. They told me on the steamer,
these New Yorkers, facts that made even the hard heart of a king
bleed for the poor devils who chased the ignis fatuus of freedom into
the very stronghold of human tyranny. These are harsh words,
Posadowski. Do you dare tell me that they are false—you who know
the East Side of that great city in which you, and thousands of
deluded Europeans, have toiled in misery that makes the lot of a
Rexanian peasant easy, even luxurious, in comparison? Perhaps I
have been misinformed. Perhaps I have failed to read aright the
newspapers that have come to my hand since I reached this
strange, distorted land. But what I have heard, what I have read,
forces me to the conviction that no Rexanian in Rexopolis has ever
suffered from a form of tyranny so pitiless as that which keeps our
countrymen in New York poorer and more hopeless than they were
in their native land. If I am wrong, if I am deceived through
insufficient data, I am sure you will set me right. Speak, man. Have I
told the truth?”
Posadowski was silent for a moment. Then he answered, a note of
stubbornness in his voice:
“Industrial conditions here are not as they should be. That is true.
But surely a monarchy would not set them right.”
“Ha!” cried Prince Carlo, “that is just the point. A monarchy would
not solve the problems of this country. On the other hand, a republic
would not remedy the defects in Rexania’s body politic. I am liberal
in my views, Posadowski. I will grant you that if I should mount the
throne of Rexania I could not rule after the fashion of my great-
grandfather. The king and his people must walk hand-in-hand to-day,
not at sword’s points. But let Rexania become a republic on the
instant, and what would result? Dissensions among the people, and
political chaos: possibly the annexation of the country by a stronger
power on our border. You talk of the selfishness of kings. Are they
not the most heroic figures of the age? Take my father—God be with
him! He has loved Rexania with a devoted unselfishness that only
those who have been near him can appreciate. Weary, sad at heart,
sometimes almost hopeless, he has had it in his power to
accumulate a vast fortune, put it into portable shape, and abandon
his country for a land in which he could live in peace and idleness.
Do you think that such a step has been no temptation to him? You
have so long looked at only one side of this matter that it will be
hard for you to realize the full force of my question. I tell you that
my father has loved Rexania with more fervor than you have ever
felt for our fatherland, that he has displayed more courage and
patriotic devotion in his life than any one of his rebellious subjects
has ever shown, and that he has understood the practical necessities
of our country’s environment better than the dreamers who have
fostered discontent among the people. My father has been a grand
and unselfish man, Posadowski, and you—you would crucify him.”
 The arch-conspirator had grown pale as the youth, with a
calmness that was almost uncanny in its exhibition of self-control,
had given voice to the thoughts that had taken form in his mind
during his days of captivity. Presently he spoke again, observing that
Posadowski had, at that moment, no arguments to advance.
“What dire calamities you may bring upon Rexania by holding me
here a prisoner I dare to contemplate. Granting that you keep me
captive from the very highest motives of patriotism, can you not see
that you are endangering the very cause for which you strive? Let us
suppose that my father dies and that Rexania becomes a republic.
Unless you kill me, Posadowski, I shall eventually return to Europe.
Not only that, but I shall be placed upon the throne of Rexania by
forces against which your republican brethren could make no
resistance worthy of the name. You are a clear-headed man,
Posadowski. I can see by your face that what I have said has made
an impression upon you that will give you, surely, a different point of
view.”
A grim smile crossed the arch-conspirator’s countenance. “I will
acknowledge, Prince Carlo, that I have not at this moment
arguments at hand to answer the line of reasoning you have
advanced. I am a slow thinker, and, as you can well understand, I
am confronted by a dilemma of tremendous import. I must ask you
to give me time to weigh your words. If, after close consideration, I
reach your conclusions—a result that necessitates the rejection of
convictions that I have cherished for many years—I will discuss
frankly with you the step that we should take.”
Posadowski arose and approached the prince.
“Let me ask you, Prince Carlo,” he said, before taking his leave,
“let me ask you not to discuss the matters we have in hand with my
colleagues. There is not one among them who would have allowed
you to explain your position as I have done. You understand me?”
“Fully,” answered the prince, smiling up at the gray-eyed
Rexanian, “I understand you, Posadowski, and I trust you.”
 At that very moment Ludovics was making his exit from a road-
house a mile away, the fumes of brandy imprisoned in the cells of
his brain. With the money that Norman Benedict had left for him at
the restaurant in St. Mark’s Square, Ludovics had purchased a
revolver and had gone on a hunting expedition into Westchester
County. It was big game that he was after—nothing less than a king
who was making wild merriment at his expense; and where that king
was Ludovics well knew.
 CHAPTER XVI.
Just below the lodge gate, and at the very top of the hill, Kate
Strong had fallen from her bicycle and sprained her ankle. The
sudden and excruciating pain had begotten a momentary faintness
that had prevented her from crying out in time to attract the
attention of Mrs. Brevoort and her brother, who were at that instant
coasting down the hillside at a merry pace.
Dizzy and sick with the shock she had sustained, Kate, realizing
that she could not recall her companions, decided to arouse Rudolph
at the lodge and send him at once for a physician. The pain in her
ankle seemed to grow worse every moment, and she began to doubt
her ability to reach the gate of her ancestral home, when an open
carriage was dragged over the top of the hill by a panting horse,
seemingly one of Westchester County’s Revolutionary relics. The
owner and driver of the ancient steed and ramshackle vehicle was
wont to remark solemnly that his faithful horse had withstood the
wear and tear of years and labor until the bicycle had begun to
haunt his footsteps. The effect of wheels operated by men upon the
nervous system of an old-fashioned and conservative horse, whose
career of usefulness had been rendered possible by the prosperity of
the livery-stable business, cannot be appreciated by a flippant mind.
In the case under our immediate consideration, the sight of a
prostrate bicycle lying by the roadside affected the aged steed
instantly. A snort, perhaps of triumph, burst from the supersensitive
horse as it planted its forefeet stubbornly in the dust of the roadway
and looked down at the overturned wheel.
The sudden halting of the carriage aroused Norman Benedict from
an intense concentration of mind. He had been attempting to decide
upon a course of action in case the rather unpromising clew he was
now following should not result in the discovery of a Rexanian who,
as he had been told, had charge of a deserted manor-house
somewhere in the neighborhood. The sight that met his eyes caused
the reporter to spring hastily from the carriage.
“Are you badly hurt?” he asked Kate Strong, who had managed to
rise to her feet by the aid of the fence toward which she had crept.
She stood with one hand on the railing, her face pale and drawn.
“I’ve sprained my ankle, I think,” she answered, trying to smile
gratefully at the stranger’s kindly interest in her plight. “If I could get
to the lodge, there, our man Rudolph could make me comfortable
until a doctor reached me.”
“Draw up here,” cried Benedict to his driver. “Put your hand on my
arm, Miss—Miss——”
“Miss Strong,” answered Kate, resting her hand on his elbow and
hobbling toward the carriage.
“Now drive slowly up to that gate,” ordered Benedict again, as he
turned and lifted Kate’s bicycle from the ground and wheeled it
along by the side of his improvised ambulance.
As the carriage stopped in front of the lodge gate, the reporter
rang a bell whose vibrations in these days of an international crisis
always gave Rudolph Smolenski’s nerves a severe shock. Since the
Crown Prince of Rexania had become his prisoner, the lodge-keeper
never opened the gate without first making a close and lengthy
examination of those who craved his attention. The tradesmen and
urchins who had occasion to beard the Rexanian in his lair had
noticed of late that he had grown surly and unsociable, and that he
allowed no one to pass the gloomy portals of a domain over which
his long service had rendered him practically autocratic.
At the moment at which Norman Benedict pulled the knob that set
a bell within the lodge a-trembling, Rudolph was deep in revery, and
wondering what would be the outcome of Posadowski’s mission to
the prince. If he had known that at that very instant Prince Carlo
was advancing arguments that tended to shake the arch-
conspirator’s devotion to the enterprise in which the Rexanian exiles
were engaged, Rudolph would have felt even greater dissatisfaction
than influenced his mood at the time. He had begun to grow
impatient and restless. He had almost become a convert to Ludovics’
belief in heroic measures. The fact was that Rudolph felt that he was
risking more than any one of his colleagues in this lawless effort to
make European history in a secluded corner of Westchester County.
The longer the temporizing policy pursued by Posadowski was
continued, the more certain was Rudolph of the ultimate discovery
of his secret and the loss of a place that was in all respects
satisfactory to his indolent and rather unsociable nature. The
thought of returning to the East Side to slave in a sweater’s
establishment filled him with horror.
There was something ominous in the sharp summons of the bell
that caused him to lay aside his pipe with trembling hand, while his
flabby cheeks turned white. He could think of no one who would be
likely to disturb the lonely lodge at that hour, unless, as he reflected
with conflicting emotions, Ludovics, the impetuous, had found his
way back to the centre of high pressure.
Hurrying toward the entrance, his heart beating with unpleasant
rapidity, Rudolph opened a peep-hole in the iron gate and looked
out. His eyes first rested on Norman Benedict: there was nothing in
the reporter’s appearance to increase the lodge-keeper’s
apprehensions. But, as his glance fell upon the carriage, drawn up
on the outside of the antique stepping-stone to the left of the
gateway, a cold perspiration broke out upon his hands and face, and
his short, puffy legs trembled beneath him. He had seen his
employer’s daughter often enough to recognize instantly the pale,
patrician face of Kate Strong. For an instant consternation rendered
him powerless. Then he turned from the gate and ran frantically
toward the manor-house. Rukacs was on guard on the front piazza.
“Rukacs,” cried the lodge-keeper, excitedly, “keep close behind the
pillars, and don’t show yourself where you can be seen from the
lodge. Tell Posadowski and the others to keep out of sight. And be
sure that not a sound issues from this house until you hear from me
again. Miss Strong, daughter of my employer, is at the lodge gate.
She looks very pale: I think she may have fainted, or something of
that kind. But keep a close watch, Rukacs. I’ll do my best to hold her
at the lodge, but you must keep your eye on the game.”
Rudolph, his legs working clumsily under the pressure of a great
crisis, rushed back to the gate, leaving Rukacs white with dismay.
The lodge, as he passed it, seemed to tremble with the noise of a
bell that froze the Rexanian’s soul with its threatening insistence.
Opening the gate, he confronted Norman Benedict.
“Miss Strong has sprained her ankle,” said the reporter, who
realized that this was no time for padding his news. “Come out and
help me to get her on to a sofa. What are you staring at, man? Don’t
you speak English?”
Rudolph made a strong effort of will and approached the carriage.
A spasm of pain crossed Kate’s face as she gave one hand to
Rudolph and the other to Benedict and stepped to the ground.
“I will go into the lodge, Rudolph,” she said. “I couldn’t stand the
motion of that old conveyance a moment longer.”
The lodge-keeper was white and speechless as he helped the
injured girl into the parlor of the lodge, while the reporter drew the
only comfortable piece of furniture in the room, an antique lounge,
toward the front windows and arranged a tattered pillow at its head.
“There is a doctor not far from here?” asked Benedict, turning to
the lodge-keeper and giving him a penetrating glance. There was
something in Rudolph’s manner that struck the quick-witted reporter
as peculiar.
“Half a mile down the road,” answered Rudolph, his voice
unsteady.
“Get into the carriage and bring him here at once,” ordered
Benedict, sharply, noting instantly the reluctance Rudolph’s manner
expressed. Kate Strong also noticed her retainer’s hesitation.
“Do as this gentleman directs, Rudolph,” she commanded; and the
lodge-keeper, seeing no alternative at hand, turned and left the
room with hesitating steps.
“Pardon me, Miss Strong,” remarked Benedict, stationing himself
at a window from which he could see the roadway, “your man is a
foreigner?”
“Yes,” answered Kate. “He is a Rexanian, I believe.” Her reply
caused the reporter to regret for the moment that he had allowed
the lodge-keeper to leave his sight. Of what significance was a girl
with a sprained ankle, compared with the greatest newspaper “beat”
of the year?
 CHAPTER XVII.
“You are to drive me half a mile down the road and back again,”
said Rudolph sullenly to the aged Jehu who had carried Nemesis in a
tumble-down vehicle to the gateway of the lodge. “Don’t stop to
think about it. The sooner its done the sooner its over.”
With this philosophical remark, the Rexanian entered the carriage
and seated himself gloomily behind the taciturn and dispirited driver.
There was a melancholy aspect to the conveyance as it moved
slowly away from the lodge gate. The broken-hearted steed seemed
to be plunged in a gloomy revery regarding the iconoclastic influence
of bicycles; the driver cracked his tattered whip in a hopeless way, as
if he realized the impotence of his efforts to give an appearance of
life and activity to his antiquated turnout; while Rudolph’s face wore
an expression of mingled apprehension and dismay that grew more
intense the farther he rolled away from the manor-house.
It was this depressing caravan that met the restless gaze of
Ludovics about a quarter of a mile below the lodge. He had cut loose
from his alcoholic moorings at the road-house, and was tacking
toward Rudolph’s ill-fated residence with a purpose much more
steady than his steps. He paused by the side of the roadway and
aroused Rudolph from his dark forebodings by a loud cry.
“Rudolph!” shouted Ludovics. “Rudolph! Have they turned you
out? Good! I knew you were the right kind! Here, man, give me the
grip.”
The little inebriate had reached the side of the carriage and seized
Rudolph’s cold, damp, flabby hand.
The lodge-keeper gazed calmly at his unruly compatriot. The
thought had entered his mind that it was possible to save time by
sending Ludovics for the doctor while he and his disheartened driver
returned to the lodge.
 “Ludovics,” remarked Rudolph, diplomatically, “I’m glad to see
you.” Then he leaned down over the back wheel and whispered, “Be
cautious, Ludovics. The driver there is not one of us.”
Ludovics flashed a glance of withering scorn at the bent back of
the phlegmatic Jehu.
“I see,” he said, with drunken gravity, “you have hypnotized him,
Rudolph. It is well.”
“Yes, that’s it,” answered the lodge-keeper, who was weighing all
the chances and trying to reach a decision. Finally he said,
“Ludovics, I must get back to the lodge at once. You passed a large
white house with pillars in front of it, about a quarter of a mile below
here. There’s a sign on the gate reading ‘Dr. C. H. Moore.’ Now I
want you to go back there and tell the doctor to come to the lodge
at once. Do you understand me?”
Ludovics drew himself up haughtily, as if Rudolph had cast a slur
upon his intellectual ability.
“Of course I understand you,” he answered, petulantly. Then a
vivid suspicion flashed through his befuddled brain.
“Tell me, Rudolph,” he cried, in low, feverish tones, “is he sick?
Didn’t his food agree with him? Ha ha! Well done, Rudolph! I knew
you were the right kind, Rudolph. He needs a doctor, does he?
Good! I’ll go and get the doctor, Rudolph. Give him something more
to eat and drink before the doctor gets there, brother. He’s a
stubborn boy, you know. But I trust you, Rudolph, I trust you. Dr.
Moore, you said? Dr. Moore? Down the road? Very good, Rudolph.
I’m off.” Ludovics laughed with a fiendish glee that horrified even the
unimpressionable lodge-keeper.
“Be careful what you say, Ludovics,” he said, harshly. “Simply ring
the bell and say that Dr. Moore is wanted at the Strongs’ manor-
house. Understand me! Don’t talk too much, or you may get into
trouble. Now go.”
 Leaning forward, Rudolph directed the driver to arouse himself
and his horse from lethargy and return to the lodge gate. A moment
later the broken-spirited horse was retracing his steps hopelessly,
while Rudolph was leaning back in his seat in a more contented
frame of mind. He had saved at least ten minutes by entrusting his
mission to Ludovics.
The latter had turned his back on the vehicle and was making his
way down the road at a pace that indicated a set purpose and a
slight recovery from alcoholic domination on his part. Suddenly he
paused, looked back at the retreating carriage, and, leaving the
road, leaned against a fence and indulged for a moment in an
inward debate. Then he took from a pocket in his coat a flask that
he had purchased at the road-house, and, removing the cork,
swallowed a fiery mouthful of the raw liquor.
“I wonder,” he said argumentatively to himself, “I wonder if
Rudolph is a truly patriotic cook? There’s a king up here in
Westchester County who needs a doctor. I’m going for the doctor. I
look well, don’t I, Ludovics, getting a doctor for a sick king? I wish I
knew how sick he is. If he’s as sick of himself as I am of kings, he’ll
die anyway.” He staggered to the road and turned again toward the
manor-house.
“I don’t think I’m a success going for doctors,” he mused. “I do
better when I’m going for kings.” He placed an unsteady hand on
the rear pocket of his trousers and satisfied himself that the revolver
he had purchased with a part of Norman Benedict’s gratuity was in
its place.
“There’s nothing so good for a sick king as pills,” he muttered.
“Pills! Pills made of lead! They’re much more certain than Rudolph’s
cooking. Rudolph means well, but he doesn’t drink enough brandy.”
As this conclusion forced itself upon him, he stopped again and
drew fresh patriotic inspiration from his flask. It was beginning to
grow dark as Ludovics reached the high fence that enclosed the
grounds of the manor-house and ran up flush with the front wall of
the lodge. The sun had sunk in the west like a glowing cannon-ball
blushing for its crimes.
“It’s lucky I’m small,” mused Ludovics, as he nimbly mounted the
railing and let himself down on the other side. For a moment it
struck him as curious that he could climb a fence with more
assurance than he could follow a roadway.
“That must be good brandy,” he muttered. “It doesn’t help my
walking much, but it makes me climb like a cat.”
Stealthily he made his way through the tangled grass that covered
the lawn until he stood beneath the balcony at the rear of the
manor-house. The waters of the Sound were leaden-hued, and the
gathering gloom of night gave a dreary aspect to the scene before
him.
“The doctor has come,” said Ludovics to himself, a mocking smile
overspreading his face as he glanced upward and saw how easy it
would be for a man of his weight and agility to reach the second
story of the manor-house. “Just where my patient is, I don’t know,
but I’m almost sure that Rudolph said he was going to put the king
in the rear room on the second floor.” The cold, damp breeze that
had arisen when the sun went down chilled the murderous little
Rexanian to the marrow: another pull at the flask was necessary to
check the trembling of his hands.
“I’ll cure him,” he continued, leaning against one of the posts that
supported the balcony. “I’ll cure him. My medicine chest is ready for
use. It never fails. When I doctor a king—eh, Ludovics?—he’s never
sick again, is he? Rudolph’s cooking is not so sure as my little pills.
One pill in a vital part, and the man is never sick again! Isn’t that
wonderful? Never sick again!”
Thus muttering to himself, Ludovics began to climb the post at the
southern end of the balcony, his teeth gleaming in the half-light as
he grinned maliciously, while his eyes glanced with feverish
eagerness at a ray of light that flared from a window above him.
 CHAPTER XVIII.
Norman Benedict had removed Kate Strong’s legging and the long
buttoned shoe that had covered her sprained ankle, and had deftly
bound up the injured member with a handkerchief, after he had
relieved the pain by applying cold water and a gentle massage.
“You have been very kind to me,” said Kate, gratefully, as she
leaned back on the sofa and realized how much more comfortable
the reporter’s skill had made her feel. “I owe you a great debt of
gratitude.” How much she was indebted to Benedict she did not fully
realize, for he had been under a strong temptation to follow Rudolph
at any cost when he had learned that the lodge-keeper was the very
Rexanian he had come up into Westchester to find.
“Your man, there,” said Benedict, questioningly, glancing at his
watch, “has he been long in your service?”
“Several years,” answered Kate. “I believe he was exiled from
Rexania after the revolution of ten years ago.”
Her remark tended to increase the reporter’s interest in the lodge-
keeper.
“They are a curious people, those Rexanians,” he remarked,
drawing a chair toward the sofa and seating himself where he could
watch Kate’s face. “I have seen something of them on the East
Side.”
Kate felt an almost irresistible desire to confess to the youth that
they were a race in which she took at that moment an interest that
was founded on a most unhappy incident.
“You see,” Benedict went on, noting the animated expression on
her face, “I am a newspaper reporter, Miss Strong, and in my work I
come into contact with many curious phases of life and queer kinds
of people in New York. Of course you have never met a Rexanian,
excepting your lodge-keeper, Rudolph?”
 “Oh, but I have,” cried Kate, who did not fully realize that her
accident had rendered her slightly feverish and therefore somewhat
more loquacious than usual. “A Rexanian dined at our house in the
city a few nights ago. He had come over on the steamer with my
father and mother. He was a very charming man.”
There was something in her voice that impressed Benedict as
peculiar.
“One of the Rexanian nobility, of course?” he asked, diplomatically.
“Yes,” she answered, with some hesitation. “He was a count—
Count Szalaki.” Her face flushed as the thought flashed through her
mind that her frankness in the presence of a newspaper reporter
was, to say the least of it, indiscreet. But there were many
influences at work to render Kate Strong less reticent than she
ordinarily was by habit and temperament. The sudden
disappearance of their Rexanian guest and the shadow that had
been cast upon his memory by her family had made her impatient to
clear up the mystery that surrounded the only man who had ever
fully satisfied the romantic longings that pertained to her youth and
her self-centred nature.
That Ned Strong was fitted neither by temperament nor by
experience to solve a problem that grew more and more inexplicable
as time passed, his sister well knew. Already he had lost interest in a
mystery that grew more important to Kate the longer it remained
unsolved. She herself was powerless to prosecute a line of inquiry
that, she felt sure, would, if carried forward to the end, exonerate
the Rexanian whose melancholy and fascinating face had impressed
her as that of a man whose soul was too lofty for subterfuge and
fraud.
Fate had thrown her into the enforced companionship of a man
whose journalistic training had thoroughly fitted him for solving
mysteries of the kind that now weighed upon her overwrought mind.
Conflicting emotions warred within her. She possessed many of the
prejudices and all the self-control that pertain to the real patrician;