Testing and Quality Assurance Flashcards
7 cards from real CCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Testing and Quality Assurance flashcards as text
A coder assigns a code for acute respiratory failure as the principal diagnosis for a patient admitted with pneumonia. The physician's final diagnosis lists only pneumonia. What should the QA auditor do?
Answer: Flag it for a physician query to clarify the principal diagnosis
The QA auditor should initiate a compliant physician query to clarify which condition was chiefly responsible for admission, rather than unilaterally changing codes.
Which statistical method is MOST commonly used to determine the appropriate sample size for a coding audit?
Answer: Random sampling with confidence interval calculation
Random sampling with confidence interval calculation provides a statistically valid and defensible sample for measuring coding accuracy rates.
During an outpatient coding audit, a reviewer finds the first-listed diagnosis is a symptom when the related definitive diagnosis is also documented. What is the error?
Answer: Violating outpatient coding guideline to code the confirmed diagnosis rather than the symptom
Outpatient coding guidelines require coders to report the confirmed definitive diagnosis rather than the signs or symptoms when both are documented.
A facility implements a CDI (Clinical Documentation Improvement) program primarily to achieve which quality goal?
Answer: Improve the accuracy and completeness of documentation to support correct code assignment
CDI programs are designed to improve clinical documentation quality so that coded data accurately reflects the patient's clinical picture and supports appropriate reimbursement.
An auditor identifies that a coder billed CPT 99215 with modifier -25 and a separate surgical procedure code on the same date. The documentation supports a significant, separately identifiable E/M service. This coding is:
Answer: Correct — modifier -25 appropriately identifies a significant separately identifiable E/M service
Modifier -25 is correctly used to indicate that a significant, separately identifiable E/M service was performed on the same day as a procedure when documentation supports it.
When performing a DRG validation audit, which finding would MOST likely result in a higher-weighted MS-DRG assignment?
Answer: A previously uncaptured MCC supported by physician documentation
Capturing a Major Complication or Comorbidity (MCC) that is supported by documentation can move a case to a higher-weighted MS-DRG, increasing reimbursement.
Which element is REQUIRED to be included in a compliant physician query according to AHIMA and ACDIS guidelines?
Answer: Clinical indicators from the medical record that prompted the query
Compliant queries must include the clinical indicators from the record that led to the query, without leading the physician toward a specific diagnosis.