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 Two-Midnight Rule requires that the admitting physician document a reasonable expectation that the patient will require hospital care spanning two midnights.

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 OIG's Seven Elements of an Effective Compliance Program provide the foundational structure for hospital compliance programs, including CDI and coding compliance.

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

The Medicare appeals process begins with a Redetermination request submitted to the MAC within 120 days of the initial determination. This is the first level of appeal.

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

Systematically sending leading or unsupported queries that result in non-clinically-supported diagnoses, then submitting Medicare claims for the resulting higher DRG, can constitute knowingly submitting false or fraudulent claims under the FCA.

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

A 'history of appendectomy' is a past procedure with no active management implications during the current stay. Historical conditions that do not affect current patient care, treatment, or monitoring do not meet the UHDDS reporting standard.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Official Coding Guidelines and Regulatory Compliance 3