CCDS Official Coding Guidelines and Regulatory Compliance 5 — Questions and Answers
Question 1: A patient is admitted with acute respiratory failure and pneumonia. The physician documents acute respiratory failure as the condition requiring the most intensive management. Per UHDDS and ICD-10-CM guidelines, what is the principal diagnosis?
- Pneumonia, because it caused the respiratory failure
- Acute respiratory failure, because it required the most resources (Correct answer)
- Both conditions are co-principal and either may be sequenced first
- Whichever condition the physician lists first in the H&P
Correct answer: Acute respiratory failure, because it required the most resources
When the attending physician identifies the condition requiring the most intensive management, that condition is selected as the principal diagnosis per UHDDS guidelines.
Question 2: Which CMS program specifically audits hospital inpatient coding accuracy on a post-payment basis and can demand repayment of improper Medicare payments?
- Comprehensive Error Rate Testing (CERT)
- Recovery Audit Contractor (RAC) program (Correct answer)
- Medicare Administrative Contractor (MAC) pre-payment review
- Quality Improvement Organization (QIO) review
Correct answer: Recovery Audit Contractor (RAC) program
Recovery Audit Contractors review Medicare claims after payment and issue demand letters for overpayments identified through improper coding.
Question 3: ICD-10-CM guideline Section I.C.19 covers coding for injuries. When multiple injuries are present, what guides principal diagnosis selection?
- Always sequence the most severe injury as principal
- Sequence the injury requiring the most surgical intervention as principal
- The most serious injury, as determined by the provider, guides sequencing (Correct answer)
- The injury listed first in the operative report is principal
Correct answer: The most serious injury, as determined by the provider, guides sequencing
When multiple injuries are present, the most serious injury as determined by the provider is sequenced as the principal diagnosis.
Question 4: A hospital receives a Targeted Probe and Educate (TPE) review notice from its MAC. What is the primary purpose of this review process?
- To impose immediate financial penalties for billing errors
- To educate providers on proper billing and reduce error rates before enforcement (Correct answer)
- To refer providers with high error rates to the OIG for exclusion
- To conduct unannounced on-site documentation audits
Correct answer: To educate providers on proper billing and reduce error rates before enforcement
TPE is an educational process in which MACs review a sample of claims, provide feedback, and offer education to help providers correct errors before stronger action is taken.
Question 5: Per ICD-10-CM Official Guidelines, which of the following correctly describes coding for pressure ulcers with multiple stages documented at the same site over the course of an inpatient stay?
- Code only the stage present on admission
- Code the highest stage documented during the stay (Correct answer)
- Code each stage separately with distinct codes
- Code the stage present at discharge only
Correct answer: Code the highest stage documented during the stay
When a pressure ulcer progresses during admission, ICD-10-CM guidelines direct assignment of the code for the highest stage documented during the stay.
Question 6: The Cooperating Parties for ICD-10-CM/PCS include all of the following EXCEPT:
- American Health Information Management Association (AHIMA)
- American Hospital Association (AHA)
- National Center for Health Statistics (NCHS)
- American Medical Association (AMA) (Correct answer)
Correct answer: American Medical Association (AMA)
The four Cooperating Parties are AHIMA, AHA, NCHS, and CMS; the AMA maintains CPT, not ICD-10-CM/PCS.
Question 7: Under ICD-10-CM guidelines, when a patient is admitted for chemotherapy and develops a complication during the inpatient stay, what is the correct principal diagnosis?
- The malignancy for which chemotherapy is being administered
- Encounter for antineoplastic chemotherapy (Z51.11) (Correct answer)
- The complication that developed during the stay
- The complication if it required surgical intervention; otherwise the malignancy
Correct answer: Encounter for antineoplastic chemotherapy (Z51.11)
ICD-10-CM guidelines specify that when admission is for chemotherapy, Z51.11 is sequenced as principal regardless of complications that arise during the stay.
CCDS Official Coding Guidelines and Regulatory Compliance 5
A patient is admitted with acute respiratory failure and pneumonia.
The physician documents acute respiratory failure as the condition requiring the most intensive management.
Per UHDDS and ICD-10-CM guidelines, what is the principal diagnosis?