CBCS Outpatient and Inpatient Coding 2 — Questions and Answers
Question 1: Under UHDDS guidelines, how many diagnoses may be reported as 'other diagnoses' (additional diagnoses) on an inpatient claim?
- Up to 4 additional diagnoses
- Up to 8 additional diagnoses
- As many as meet the reporting criteria (Correct answer)
- None — only the principal diagnosis is reported
Correct answer: As many as meet the reporting criteria
UHDDS guidelines allow reporting of all additional diagnoses that meet specified criteria — there is no fixed maximum number.
UHDDS guidelines specify that 'other diagnoses' (additional diagnoses beyond the principal) should be reported for all conditions that coexist at the time of admission, or develop subsequently, and affect the patient's care or treatment during the encounter. There is no set maximum number of additional diagnoses — all qualifying conditions should be reported. However, claim form and software limitations may impose practical limits, and CMS claim processing supports up to 25 diagnoses on a UB-04.
Question 2: What does ICD-10-PCS stand for, and where is it used?
- ICD-10 Procedural Coding System, used for outpatient physician coding
- ICD-10 Procedure Coding System, used for inpatient hospital procedures (Correct answer)
- ICD-10 Pharmaceutical Classification System, used for drug coding
- ICD-10 Physical Coding Standards, used for physical therapy procedures
Correct answer: ICD-10 Procedure Coding System, used for inpatient hospital procedures
ICD-10-PCS is the ICD-10 Procedure Coding System used exclusively for inpatient hospital procedure coding.
ICD-10-PCS (ICD-10 Procedure Coding System) was developed by CMS for use in the inpatient hospital setting. Unlike CPT codes (used by physicians and in outpatient settings), ICD-10-PCS codes are 7 characters long, with each character having a specific meaning (section, body system, root operation, body part, approach, device, qualifier). ICD-10-PCS codes are used on the UB-04 claim form for hospital inpatient procedures and affect DRG assignment.
Question 3: Which of the following is the claim form used for inpatient hospital billing?
- CMS-1500
- UB-04 (CMS-1450) (Correct answer)
- ADA Dental Claim Form
- HCFA-1500
Correct answer: UB-04 (CMS-1450)
The UB-04 (also called CMS-1450) is the standard institutional claim form used by hospitals for inpatient billing.
The UB-04 (Uniform Bill-04, also known as CMS-1450) is the standard institutional claim form used by hospitals and other facilities (inpatient, outpatient, skilled nursing facilities, home health agencies) to bill Medicare and most other payers. Physicians and non-institutional providers use the CMS-1500 form. The UB-04 includes revenue codes, condition codes, and value codes that are unique to facility billing.
Question 4: What is a 'complication of care' in ICD-10-CM coding?
- Any adverse outcome occurring after a surgical procedure
- A condition arising as a result of medical or surgical management, coded from the T80-T88 category (Correct answer)
- A secondary diagnosis that increases the DRG weight
- Any condition the patient developed during the hospitalization
Correct answer: A condition arising as a result of medical or surgical management, coded from the T80-T88 category
Complications of care are specific conditions arising from medical or surgical treatment, coded from categories T80-T88 in ICD-10-CM.
Complications of care (T80-T88) are conditions that arise specifically as a result of medical or surgical intervention, such as a post-procedural infection, seroma, or reaction to a device. Not every condition occurring after a procedure is automatically a complication of care — the physician must document a causal relationship between the treatment and the complication. Conditions that are expected sequelae of a procedure or inherent complications of the disease process are not coded as complications of care.
Question 5: In ICD-10-CM, which POA indicator is assigned when the condition could not be determined as present on admission or not?
- Y (Yes)
- N (No)
- U (Unknown) (Correct answer)
- W (Clinically undetermined)
Correct answer: U (Unknown)
POA indicator 'U' is used when documentation is insufficient to determine if a condition was present at the time of admission.
The Present on Admission (POA) indicators are: Y (yes, present at the time of admission), N (no, not present at admission, i.e., a hospital-acquired condition), U (unknown/insufficient documentation), and W (clinically undetermined — the provider is unable to clinically determine whether the condition was present at admission). The 'U' indicator is used when the medical record documentation is insufficient to determine POA status and a query to the physician does not result in clarification.
Question 6: What is 'DRG creep' or 'upcoding' in inpatient billing?
- Proper coding that accurately reflects the complexity of care
- The inappropriate practice of assigning higher-paying diagnosis codes not supported by documentation (Correct answer)
- A natural trend toward more complex DRG assignments as care becomes more complex
- The legitimate optimization of coding through clinical documentation improvement
Correct answer: The inappropriate practice of assigning higher-paying diagnosis codes not supported by documentation
DRG creep refers to the fraudulent assignment of codes for more complex diagnoses to increase reimbursement without adequate documentation support.
DRG creep (also called upcoding) refers to the practice of assigning diagnosis codes for more severe or complex conditions than are actually documented in the medical record, in order to obtain a higher-paying DRG assignment. This is considered fraud when done intentionally. It is distinct from Clinical Documentation Improvement (CDI), which is the legitimate process of working with physicians to capture a complete and accurate clinical picture. Upcoding can result in Medicare recoupment, OIG investigations, and False Claims Act liability.
Question 7: Which revenue code on the UB-04 indicates medical/surgical room and board — private?
- Revenue code 010x
- Revenue code 011x (Correct answer)
- Revenue code 012x
- Revenue code 020x
Correct answer: Revenue code 011x
Revenue code 011x (0110-0119) identifies accommodation charges for private room medical/surgical care.
Revenue codes on the UB-04 identify the type of service provided. Revenue code 0110 (or the 011x series) covers private room, medical/surgical accommodation charges. Revenue code 0120 covers semiprivate rooms (two beds), and 0100 covers all-inclusive room and board. Revenue codes are required on UB-04 claims to classify the services being billed and are unique to facility billing (not used on CMS-1500 forms).
Question 8: When a patient is admitted through the emergency department for a condition that differs from the final principal diagnosis, which condition is coded as principal?
- The ED diagnosis upon arrival
- The condition established after study to be chiefly responsible for the admission (Correct answer)
- The most expensive condition to treat
- The condition the patient presented with in the ED
Correct answer: The condition established after study to be chiefly responsible for the admission
The principal diagnosis is determined after all study — it is the condition established as chiefly responsible for the admission, even if it differs from the initial ED presentation.
Per UHDDS guidelines, the principal diagnosis is 'that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.' The key phrase is 'after study' — meaning after all evaluation, testing, and workup has been completed. The initial presenting complaint in the ED may differ from the final principal diagnosis, and coders should sequence based on what was determined after the full clinical assessment.
CBCS Outpatient and Inpatient Coding 2
Under UHDDS guidelines, how many diagnoses may be reported as 'other diagnoses' (additional diagnoses) on an inpatient claim?