CCS Testing and Quality Assurance 2 — Questions and Answers
Question 1: Which auditing method involves reviewing a sample of medical records AFTER the claim has been submitted and paid?
- Prospective audit
- Concurrent audit
- Retrospective audit (Correct answer)
- Compliance audit
Correct answer: Retrospective audit
Retrospective audits review records and claims after payment has been made to identify errors and overpayments.
Question 2: A coding quality audit reveals a coder consistently assigns codes without referencing the Alphabetic Index first. This violates which ICD-10-CM guideline?
- Etiology/manifestation convention
- Code first instruction
- Use the Alphabetic Index to locate a code before verifying in the Tabular List (Correct answer)
- Excludes1 note rule
Correct answer: Use the Alphabetic Index to locate a code before verifying in the Tabular List
Official ICD-10-CM guidelines require coders to use the Alphabetic Index to locate a code, then verify it in the Tabular List.
Question 3: What is the PRIMARY purpose of a charge capture audit in a healthcare facility?
- To verify physician credentials
- To ensure all billable services are captured and coded accurately (Correct answer)
- To review patient satisfaction scores
- To assess nurse-to-patient staffing ratios
Correct answer: To ensure all billable services are captured and coded accurately
Charge capture audits ensure that all services rendered are accurately documented, coded, and billed to prevent revenue loss or overbilling.
Question 4: During a CCS quality review, an auditor finds a principal diagnosis was selected that is not supported by physician documentation. This represents which type of error?
- Upcoding
- Unbundling
- Medical necessity error
- Unsupported code assignment (Correct answer)
Correct answer: Unsupported code assignment
An unsupported code assignment occurs when codes are selected without adequate physician documentation to substantiate them.
Question 5: When evaluating CPT coding accuracy, which resource serves as the AUTHORITATIVE source for bundling edits?
- ICD-10-PCS tables
- National Correct Coding Initiative (NCCI) edits (Correct answer)
- MS-DRG grouper software
- UHDDS definitions
Correct answer: National Correct Coding Initiative (NCCI) edits
CMS's National Correct Coding Initiative (NCCI) edits define which CPT procedure codes cannot be billed together for the same patient on the same date.
Question 6: A quality improvement team finds the facility's complication and comorbidity (CC) capture rate is below the national benchmark. What is the BEST initial step?
- Reduce staff caseloads immediately
- Conduct targeted education on CC/MCC documentation and coding guidelines (Correct answer)
- Switch to a different encoder software
- Appeal all underpaid claims
Correct answer: Conduct targeted education on CC/MCC documentation and coding guidelines
Targeted education on CC/MCC identification and proper documentation query processes is the most effective first step to improve capture rates.
Question 7: Which of the following BEST describes a 'false claim' under the False Claims Act relevant to coding compliance?
- A claim submitted with minor typographical errors in patient demographics
- A claim submitted with a diagnosis code not supported by medical record documentation (Correct answer)
- A claim submitted after the filing deadline
- A claim submitted for a non-covered service with proper notice to the patient
Correct answer: A claim submitted with a diagnosis code not supported by medical record documentation
Under the False Claims Act, submitting a claim with diagnosis codes not supported by medical record documentation constitutes a false claim and may result in significant penalties.
CCS Testing and Quality Assurance 2
Which auditing method involves reviewing a sample of medical records AFTER the claim has been submitted and paid?