Certified Medical Coding Specialist Professional Standards & Competencies 5 — Questions and Answers
Question 1: When a physician documents 'acute on chronic systolic heart failure,' a coder should:
- Assign only the acute code because it is the current presentation
- Assign only the chronic code as the underlying condition
- Assign a combination code that captures both the acute and chronic components (Correct answer)
- Query the physician because the two terms cannot be coded together
Correct 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.
Question 2: Which of the following is a characteristic of a leading or directive physician query?
- It presents multiple diagnosis options without suggesting a preferred answer
- It asks the physician to choose from clinically reasonable options
- It asks 'Would you agree that this is sepsis?' without other options (Correct answer)
- It references specific clinical indicators in the record
Correct 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.
Question 3: 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?
- A V-code for personal history
- An external cause code to describe the mechanism and place of occurrence (Correct answer)
- A Z-code for encounter type
- A morphology code for fracture type
Correct 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.
Question 4: Which of the following best defines 'medical necessity' in the context of claims submission?
- The procedure is one the patient specifically requested
- The service is reasonable and necessary for the diagnosis or treatment of illness or injury (Correct answer)
- The provider performs the service because no other provider is available
- The service is covered under the patient's insurance plan
Correct 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.
Question 5: Under the Stark Law (physician self-referral law), a physician is generally prohibited from:
- Treating Medicare patients in a solo practice
- Referring Medicare patients to entities in which they have a financial relationship (Correct answer)
- Billing Medicare for services performed in a hospital
- Employing mid-level providers in their practice
Correct 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.
Question 6: 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:
- Appropriate historical coding
- Overcoding — reporting diagnoses not relevant to the current encounter (Correct answer)
- Using the problem list as a secondary source, which is acceptable
- An ICD-10 sequencing error only
Correct 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.
Question 7: A medical coder who identifies a suspected compliance violation in their department should FIRST:
- Contact the state medical board
- Post the concern anonymously on a public forum
- Report through the organization's internal compliance hotline or to the compliance officer (Correct answer)
- Refuse to code any claims until the issue is resolved
Correct 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.
Certified Medical Coding Specialist Professional Standards & Competencies 5
When a physician documents 'acute on chronic systolic heart failure,' a coder should: