CDIP Coding and Reimbursement 3 — Questions and Answers
Question 1: Under the Outpatient Prospective Payment System (OPPS), what determines the Ambulatory Payment Classification (APC) assigned to a service?
- Principal diagnosis and length of visit
- HCPCS/CPT code for the service performed (Correct answer)
- Patient's insurance type and discharge status
- Number of diagnoses coded on the claim
Correct answer: HCPCS/CPT code for the service performed
APC assignment under OPPS is driven primarily by the HCPCS/CPT procedure code submitted on the outpatient claim, grouping clinically similar services with similar resource use.
Question 2: A physician documents 'Type 2 diabetes with diabetic nephropathy.' Which ICD-10-CM guideline applies to coding this combination?
- Code only the diabetes; nephropathy is assumed unrelated
- Use a combination code that captures both conditions in a single code (Correct answer)
- Code nephropathy as the principal diagnosis with diabetes secondary
- Code separately with an 'and' convention linking both codes
Correct answer: Use a combination code that captures both conditions in a single code
ICD-10-CM provides combination codes for diabetes with associated complications; a single code captures both the type 2 diabetes and the diabetic nephropathy.
Question 3: What is the significance of the 'CC/MCC exclusion list' in MS-DRG grouping?
- It lists diagnoses that are never reported as secondary codes
- It identifies secondary diagnoses that cannot act as CC/MCC when the principal diagnosis is a related condition (Correct answer)
- It excludes certain procedures from DRG calculation
- It defines which codes qualify for POA exemption
Correct answer: It identifies secondary diagnoses that cannot act as CC/MCC when the principal diagnosis is a related condition
The CC/MCC exclusion list prevents double-counting by identifying pairs where a secondary condition cannot serve as a CC or MCC because it is too closely related to the principal diagnosis.
Question 4: A hospital receives a claim denial because a procedure code is not supported by the documented diagnosis. This is an example of which type of coding error?
- Upcoding
- Medical necessity failure (Correct answer)
- Unbundling
- Duplicate billing
Correct answer: Medical necessity failure
Medical necessity requires that the diagnosis code(s) support the clinical appropriateness of the procedure performed; a mismatch between diagnosis and procedure leads to medical necessity denials.
Question 5: Which ICD-10-CM code category is used to capture external causes of morbidity, such as the mechanism and place of a patient's injury?
- Z codes
- V, W, X, Y codes (Correct answer)
- S and T codes
- E codes (legacy ICD-9)
Correct answer: V, W, X, Y codes
ICD-10-CM uses V, W, X, and Y code categories to capture external causes of injury and morbidity, including mechanism, intent, and place of occurrence.
Question 6: Under ICD-10-PCS, which approach value is used when a procedure is performed entirely through a natural or artificial opening?
- Open
- Percutaneous
- Via Natural or Artificial Opening (Correct answer)
- External
Correct answer: Via Natural or Artificial Opening
ICD-10-PCS approach value '7' (Via Natural or Artificial Opening) is used when instruments are introduced through a natural body opening or an artificially created one, such as a cystoscopy via the urethra.
Question 7: What is 'charge capture' in the context of hospital revenue cycle management?
- The process of collecting payment from patients at discharge
- The process of recording all billable services rendered to generate an accurate claim (Correct answer)
- The method for calculating DRG relative weights
- The auditing of claims after submission to payers
Correct answer: The process of recording all billable services rendered to generate an accurate claim
Charge capture is the process by which all services, supplies, and procedures provided to a patient are recorded so they can be billed accurately, forming the foundation of claim generation.
CDIP Coding and Reimbursement 3
Under the Outpatient Prospective Payment System (OPPS), what determines the Ambulatory Payment Classification (APC) assigned to a service?