CCDS Official Coding Guidelines and Regulatory Compliance 2 — Questions and Answers
Question 1: Under ICD-10-CM Official Guidelines, the 'Excludes1' note indicates:
- The excluded code may be used together with the code it is excluded from
- The two conditions cannot occur simultaneously and cannot be coded together (Correct answer)
- The excluded code should always be sequenced before the primary code
- The condition is included in the code and should not be coded separately
Correct 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.
ICD-10-CM uses two types of excludes notes with distinct meanings. Excludes1 ('Not coded here') means the excluded condition is incompatible with the code under which it appears. The two conditions cannot coexist simultaneously by definition.
Question 2: Which federal agency is responsible for maintaining and updating the ICD-10-CM code set?
- The American Hospital Association (AHA)
- CMS and the National Center for Health Statistics (NCHS) (Correct answer)
- The American Health Information Management Association (AHIMA)
- The Department of Veterans Affairs (VA)
Correct 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.
The ICD-10-CM system is a US clinical modification of the WHO's ICD-10, maintained cooperatively by CMS and NCHS. Annual updates to both systems are released in the spring with an October 1 implementation date.
Question 3: 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?
- UHDDS reporting requirements for secondary diagnoses
- ICD-10-CM coding guideline requiring physician documentation to support diagnoses (Correct answer)
- CMS MS-DRG Grouper calculation methodology
- The Joint Commission medical record completion standards
Correct 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.
ICD-10-CM Official Coding Guidelines state that the physician or other qualified provider is the appropriate source for diagnosis coding. Assigning a CC or MCC code based solely on nursing notes without physician documentation constitutes coding without a valid clinical basis.
Question 4: Which OIG program provides annual guidance on high-risk healthcare compliance areas including CDI and coding?
- Medicare Administrative Contractor (MAC) Local Coverage Determinations
- OIG Work Plan and annual compliance program guidance (Correct answer)
- Recovery Audit Contractor (RAC) denial trend reports
- CMS PEPPER reports
Correct 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.
The OIG Work Plan identifies areas of Medicare and Medicaid fraud and abuse risk that will be subject to audits, investigations, and compliance guidance. CDI programs use Work Plan items as a guide for internal compliance audits and documentation education priorities.
Question 5: Under the Cooperating Parties coding guidelines, which organization provides the official publication for ICD-10-CM/PCS coding advice?
- ACDIS (Association of Clinical Documentation Integrity Specialists)
- AHA Coding Clinic for ICD-10-CM/PCS (Correct answer)
- CMS Medicare Claims Processing Manual
- AHIMA Standards of Ethical Coding
Correct 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).
The Cooperating Parties including CMS, NCHS, AHA, and AHIMA jointly approve ICD-10-CM/PCS guidance. The AHA Coding Clinic is the official vehicle for this guidance. Coding Clinic decisions represent authoritative guidance that supersedes internal facility policies or unofficial sources.
Question 6: A PEPPER report shows a hospital is a statistical outlier for 'one-day stays.' What does this indicate from a CDI compliance perspective?
- The hospital is efficiently discharging patients, reflecting strong care quality
- The hospital may have admissions that do not meet inpatient criteria and should review medical necessity documentation (Correct answer)
- One-day stays are a sign of appropriate CDI query activity
- PEPPER outlier status requires immediate self-disclosure to the OIG
Correct 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.
PEPPER reports provide CMS-generated statistical data comparing a hospital's Medicare payment patterns against state, MAC jurisdiction, and national benchmarks. Outlier status for one-day stays suggests a pattern of short inpatient admissions that may not meet Two-Midnight Rule criteria.
CCDS Official Coding Guidelines and Regulatory Compliance 2
Under ICD-10-CM Official Guidelines, the 'Excludes1' note indicates: