CCDS Official Coding Guidelines and Regulatory Compliance 3

Question 1

Under the Two-Midnight Rule, which physician documentation element is MOST critical to support an inpatient admission?

Accepted Answer

The admitting physician's documented expectation that care will span at least two midnights

Answer

The patient's insurance type and pre-authorization number

Answer

The number of procedures performed during the stay

Answer

The patient's out-of-pocket cost estimate and financial counseling note

Question 2

Which compliance framework do hospitals use to structure internal CDI and coding compliance programs?

Accepted Answer

The OIG Seven Elements of an Effective Compliance Program

Answer

The UHDDS Data Element Reporting Requirements

Answer

The Joint Commission ORYX Performance Measurement System

Answer

The CMS Conditions of Participation for Medical Records

Question 3

A Recovery Audit Contractor (RAC) denies payment for a sepsis claim. What is the FIRST step in the appeals process?

Accepted Answer

Submit a Redetermination request to the Medicare Administrative Contractor (MAC) within the allowed timeframe

Answer

Self-disclose the underpayment to CMS immediately

Answer

Recode the claim to a less complex DRG and resubmit

Answer

Request a Qualified Independent Contractor (QIC) review as the initial step

Question 4

Under the False Claims Act (FCA), which of the following scenarios could create liability for a hospital's CDI program?

Accepted Answer

Systematically sending leading queries that result in diagnoses not clinically supported, then submitting claims

Answer

Querying physicians about clinical indicators found in the medical record

Answer

Using concurrent review to identify documentation gaps before discharge

Answer

Tracking query response rates and educating physicians on documentation specificity

Question 5

The UHDDS requires that secondary diagnoses be reported only when they affect patient care. Which of the following should NOT be reported?

Accepted Answer

A historical finding documented as 'history of appendectomy 10 years ago'

Answer

Hypertension managed with continued home medications during the hospitalization

Answer

Chronic kidney disease affecting medication dosing decisions

Answer

Type 2 diabetes requiring insulin management during the stay

Question 6

Which CMS enforcement mechanism involves withholding Medicare payment for claims with specific diagnosis codes to investigate compliance with coding guidelines?

Accepted Answer

Pre-Payment Review by Medicare Administrative Contractors (MACs)

Answer

Recovery Audit Contractors (RACs)

Answer

Comprehensive Error Rate Testing (CERT)

Answer

Hospital-Acquired Condition payment adjustment