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 QA audit reveals a 10% error rate in a coder's work. According to most facility benchmarks, which action is MOST appropriate?
Answer: Provide focused education and re-audit within 30–90 days
A 10% error rate typically triggers focused education followed by re-auditing; most facilities target 95% or higher accuracy rates.
Which of the following scenarios represents 'upcoding' that a CCS quality auditor should flag?
Answer: Billing a Level 5 E/M when documentation only supports a Level 3
Upcoding occurs when a higher-level code is assigned than what the medical record documentation actually supports, resulting in improper overpayment.
Under the UHDDS definitions used for inpatient coding, the 'principal diagnosis' is defined as:
Answer: The condition established after study to be chiefly responsible for occasioning the patient's admission
UHDDS defines the principal diagnosis as the condition established after study to be chiefly responsible for causing the patient's hospital admission.
A coding quality review finds that coders are not coding all conditions that meet the UHDDS definition of 'additional diagnoses.' What is the MOST likely financial impact?
Answer: Underpayment due to missed CC/MCC capture affecting MS-DRG assignment
Failing to code all valid additional diagnoses means CCs and MCCs may be missed, resulting in lower MS-DRG weights and underpayment for the facility.
Which of the following is an example of 'unbundling' that a CCS auditor should identify and correct?
Answer: Billing component codes separately when a comprehensive CPT code describes the entire service
Unbundling means billing separate component codes for services that should be reported with a single comprehensive CPT code, which violates NCCI rules.
During a facility compliance audit, which payer's edits should be checked FIRST when evaluating inpatient hospital claim accuracy?
Answer: CMS Medicare guidelines and MS-DRG grouper logic
CMS Medicare guidelines, including MS-DRG grouper logic and IPPS rules, are the primary reference for inpatient hospital claim accuracy and compliance.
A coder assigns a 'probable' diagnosis as definitive for an inpatient record per ICD-10-CM guideline Section II.H. A QA auditor reviews the case — this coding is:
Answer: Correct — inpatient guidelines allow coding of qualified diagnoses such as 'probable' if documented at discharge
ICD-10-CM Section II.H permits inpatient coders to code qualified diagnoses (probable, suspected, likely, etc.) if documented at the time of discharge as the condition after study.