CCDS Official Coding Guidelines and Regulatory Compliance 4 — Questions and Answers
Question 1: Under ICD-10-CM Official Guidelines, when a patient is admitted for a complication of a previous surgery performed at another facility, what is the principal diagnosis?
- The original condition that required surgery
- The postoperative complication itself (Correct answer)
- The surgical procedure performed at the other facility
- The reason the patient sought care at the current facility
Correct answer: The postoperative complication itself
The postoperative complication is coded as the principal diagnosis when the patient is admitted specifically to treat that complication.
Question 2: Which federal regulation requires hospitals to report inpatient data using the Uniform Hospital Discharge Data Set (UHDDS) definitions?
- HIPAA Privacy Rule
- CMS Conditions of Participation
- Medicare Inpatient Prospective Payment System final rule (Correct answer)
- Office of Inspector General (OIG) Work Plan
Correct answer: Medicare Inpatient Prospective Payment System final rule
The CMS IPPS final rule incorporates UHDDS definitions and mandates their use for Medicare inpatient reporting.
Question 3: According to ICD-10-CM guidelines, how should 'probable' diagnoses be coded in the outpatient/physician office setting?
- Code the probable diagnosis as confirmed
- Code only the signs and symptoms, not the probable diagnosis (Correct answer)
- Code the probable diagnosis with a 'suspected' qualifier code
- Assign an unspecified code from the appropriate chapter
Correct answer: Code only the signs and symptoms, not the probable diagnosis
In outpatient settings, uncertain diagnoses (probable, suspected, rule-out) are coded to the highest degree of certainty — typically signs and symptoms.
Question 4: The National Coverage Determinations (NCDs) issued by CMS are binding on which entities?
- Only Medicare Advantage plans
- All Medicare contractors and providers nationwide (Correct answer)
- Only acute care hospitals participating in Medicare
- State Medicaid programs only
Correct answer: All Medicare contractors and providers nationwide
NCDs apply uniformly to all Medicare contractors and providers across the country, unlike Local Coverage Determinations which are contractor-specific.
Question 5: When coding a patient with HIV disease who is admitted for an unrelated condition (e.g., a broken leg), what is the correct sequencing per ICD-10-CM guidelines?
- Always sequence B20 (HIV disease) as the principal diagnosis (Correct answer)
- Sequence the unrelated condition first, with B20 as an additional code
- Do not code HIV if it was not treated during the encounter
- Sequence whichever condition required more resources as principal
Correct answer: Always sequence B20 (HIV disease) as the principal diagnosis
ICD-10-CM guidelines instruct that B20 is always sequenced as the principal diagnosis when a patient with HIV is admitted, regardless of the reason for admission.
Question 6: Under the Outpatient Code Editor (OCE), which edit would cause a claim to be returned to a provider for correction?
- A diagnosis code not acceptable as a first-listed code on an outpatient claim (Correct answer)
- Use of a valid ICD-10-CM code that has no CPT pairing requirement
- A procedure code that maps to a high-weighted APC
- Reporting more than five diagnosis codes on a single claim
Correct answer: A diagnosis code not acceptable as a first-listed code on an outpatient claim
The OCE flags diagnosis codes designated as 'unacceptable principal diagnosis' (e.g., manifestation codes), triggering a return-to-provider edit.
Question 7: The ICD-10-CM guideline for 'code also' notes instructs the coder to:
- Assign the 'code also' code only if the condition is documented as present (Correct answer)
- Always assign both codes in the stated order
- Assign the 'code also' code only when it affects treatment or management
- Sequence the 'code also' code as the principal diagnosis
Correct answer: Assign the 'code also' code only if the condition is documented as present
'Code also' notes indicate that a second code may be needed if the underlying condition is documented; if not documented, only the primary code is assigned.
CCDS Official Coding Guidelines and Regulatory Compliance 4
Under ICD-10-CM Official Guidelines, when a patient is admitted for a complication of a previous surgery performed at another facility, what is the principal diagnosis?