CCS Testing and Quality Assurance 3 — Questions and Answers
Question 1: 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?
- Accept the coder's assignment since acute respiratory failure is more specific
- Flag it for a physician query to clarify the principal diagnosis (Correct answer)
- Automatically change the principal diagnosis to pneumonia
- Leave the code unchanged to protect MS-DRG reimbursement
Correct 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.
Question 2: Which statistical method is MOST commonly used to determine the appropriate sample size for a coding audit?
- Stratified purposive sampling
- Random sampling with confidence interval calculation (Correct answer)
- Systematic convenience sampling
- Voluntary self-reporting
Correct 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.
Question 3: 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?
- Upcoding the E/M level
- Violating outpatient coding guideline to code the confirmed diagnosis rather than the symptom (Correct answer)
- Assigning an Excludes2 code incorrectly
- Using an invalid ICD-10-CM code
Correct 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.
Question 4: A facility implements a CDI (Clinical Documentation Improvement) program primarily to achieve which quality goal?
- Reduce the number of physician queries submitted
- Improve the accuracy and completeness of documentation to support correct code assignment (Correct answer)
- Increase the number of MS-DRGs assigned per admission
- Limit coder access to the medical record
Correct 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.
Question 5: 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:
- Incorrect — E/M services cannot be billed same day as a procedure
- Correct — modifier -25 appropriately identifies a significant separately identifiable E/M service (Correct answer)
- Incorrect — modifier -57 should be used instead for all procedures
- Correct only if the procedure is minor surgery
Correct 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.
Question 6: When performing a DRG validation audit, which finding would MOST likely result in a higher-weighted MS-DRG assignment?
- A principal diagnosis change from a CC-qualifying condition to a non-CC condition
- A previously uncaptured MCC supported by physician documentation (Correct answer)
- Removal of a procedure code with no impact on DRG
- Correction of a patient's date of birth
Correct 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.
Question 7: Which element is REQUIRED to be included in a compliant physician query according to AHIMA and ACDIS guidelines?
- The coder's suggested diagnosis
- Clinical indicators from the medical record that prompted the query (Correct answer)
- The financial impact of the requested clarification
- The patient's insurance information
Correct 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.
CCS Testing and Quality Assurance 3
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?