Professional Standards & Competencies Flashcards
7 cards from real Certified Medical Coding Specialist practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Professional Standards & Competencies flashcards as text
When a physician documents 'acute on chronic systolic heart failure,' a coder should:
Answer: Assign a combination code that captures both the acute and chronic components
ICD-10-CM provides combination codes for conditions such as acute on chronic heart failure that capture both components in a single code.
Which of the following is a characteristic of a leading or directive physician query?
Answer: It asks 'Would you agree that this is sepsis?' without other options
A leading query suggests the desired answer and is non-compliant; compliant queries offer clinically supported options or open-ended choices.
A patient is admitted for a hip fracture resulting from a fall from a ladder at a construction site. Which additional code type should be reported?
Answer: An external cause code to describe the mechanism and place of occurrence
External cause codes capture the mechanism of injury (fall from ladder) and the place of occurrence (construction site) to provide complete injury data.
Which of the following best defines 'medical necessity' in the context of claims submission?
Answer: The service is reasonable and necessary for the diagnosis or treatment of illness or injury
Medical necessity means the service is reasonable, necessary, and appropriate for the patient's condition based on accepted medical standards.
Under the Stark Law (physician self-referral law), a physician is generally prohibited from:
Answer: Referring Medicare patients to entities in which they have a financial relationship
The Stark Law prohibits physicians from referring Medicare patients to entities with which the physician has a financial relationship, unless an exception applies.
A compliance audit reveals that a coder has been consistently assigning codes for conditions that are only listed in the patient's problem list without mention in the current visit documentation. This is an example of:
Answer: Overcoding — reporting diagnoses not relevant to the current encounter
Coders must not report conditions from the problem list unless the provider addresses or documents them as relevant to the current encounter.
A medical coder who identifies a suspected compliance violation in their department should FIRST:
Answer: Report through the organization's internal compliance hotline or to the compliance officer
Established compliance programs require that suspected violations be reported internally through designated channels such as the compliance hotline or compliance officer.