Official Coding Guidelines and Regulatory Compliance Flashcards
6 cards from real CCDS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Official Coding Guidelines and Regulatory Compliance flashcards as text
Under ICD-10-CM Official Guidelines, the 'Excludes1' note indicates:
Answer: The two conditions cannot occur simultaneously and cannot be coded together
An Excludes1 note indicates a pure exclusion. The two conditions are mutually exclusive and cannot coexist in the same patient. Therefore they cannot be coded together.
Which federal agency is responsible for maintaining and updating the ICD-10-CM code set?
Answer: CMS and the National Center for Health Statistics (NCHS)
ICD-10-CM is maintained jointly by CMS and the National Center for Health Statistics (NCHS), a division of the CDC. CMS maintains ICD-10-PCS for the procedural code set used in inpatient settings.
A hospital's internal audit reveals that coders have been assigning a CC-designated secondary diagnosis code that is not clinically supported by physician documentation but is mentioned in nursing notes. This practice violates which standard?
Answer: ICD-10-CM coding guideline requiring physician documentation to support diagnoses
ICD-10-CM Official Guidelines require that diagnoses be documented by the attending physician or other qualified provider, not nursing staff. Using nursing notes alone to assign a secondary diagnosis code violates coding guidelines.
Which OIG program provides annual guidance on high-risk healthcare compliance areas including CDI and coding?
Answer: OIG Work Plan and annual compliance program guidance
The OIG Work Plan, published annually, identifies high-risk areas for fraud and abuse including CDI-related issues such as inpatient admission criteria, DRG upcoding, and specific diagnosis documentation.
Under the Cooperating Parties coding guidelines, which organization provides the official publication for ICD-10-CM/PCS coding advice?
Answer: AHA Coding Clinic for ICD-10-CM/PCS
AHA Coding Clinic for ICD-10-CM/PCS is the official publication for coding guidance, published by the American Hospital Association under the authority of the Cooperating Parties (CMS, NCHS, AHA, AHIMA).
A PEPPER report shows a hospital is a statistical outlier for 'one-day stays.' What does this indicate from a CDI compliance perspective?
Answer: The hospital may have admissions that do not meet inpatient criteria and should review medical necessity documentation
Statistical outlier status on PEPPER for one-day stays may indicate that patients are being admitted as inpatients when they should have been placed in observation status, suggesting possible medical necessity documentation issues.