CRCR Charge Capture and Coding 3 — Questions and Answers
Question 1: When coding outpatient services, which diagnosis should be sequenced first when a definitive diagnosis has not been established?
- The patient's chronic condition
- The sign, symptom, or finding that prompted the visit (Correct answer)
- The most expensive diagnosis
- The diagnosis with the highest DRG weight
Correct answer: The sign, symptom, or finding that prompted the visit
Per outpatient coding guidelines, when no definitive diagnosis is confirmed, the sign, symptom, or condition chiefly responsible for the visit is coded first.
Question 2: Which of the following best describes 'unbundling' in medical coding?
- Using a single comprehensive code when multiple codes are available
- Billing separately for components of a procedure that should be reported as one comprehensive code (Correct answer)
- Billing for a higher level of service than documented
- Combining two diagnoses into a single code
Correct answer: Billing separately for components of a procedure that should be reported as one comprehensive code
Unbundling is the practice of using multiple procedure codes for services that should be reported under a single, more comprehensive code, inflating reimbursement.
Question 3: Under the MS-DRG system, what primarily determines the DRG assignment for an inpatient stay?
- The patient's age and length of stay only
- The principal diagnosis, secondary diagnoses, procedures, age, sex, and discharge status (Correct answer)
- The total number of procedures performed
- The payer type and patient's insurance plan
Correct answer: The principal diagnosis, secondary diagnoses, procedures, age, sex, and discharge status
MS-DRG grouping uses the principal diagnosis, CC/MCC conditions, procedures, age, sex, and discharge disposition to classify patients into a reimbursement group.
Question 4: A hospital bills Medicare for a higher-complexity E/M service than what the documentation supports. This is known as:
- Downcoding
- Upcoding (Correct answer)
- Unbundling
- Coding creep
Correct answer: Upcoding
Upcoding means billing for a more expensive or higher-level service than what was actually documented or provided, which is a form of fraud.
Question 5: What is the function of NCCI (National Correct Coding Initiative) edits?
- To assign diagnosis codes to inpatient stays
- To prevent inappropriate payment of procedure codes that should not be billed together (Correct answer)
- To verify patient eligibility for Medicare
- To establish reimbursement rates for outpatient services
Correct answer: To prevent inappropriate payment of procedure codes that should not be billed together
NCCI edits are CMS-developed code pair edits that identify procedure code combinations that should not be billed together for the same patient on the same date.
Question 6: Which of the following is an example of a Major Complication or Comorbidity (MCC) under the MS-DRG system?
- Mild hypertension
- Acute respiratory failure (Correct answer)
- Routine urinary tract infection
- Osteoarthritis of the knee
Correct answer: Acute respiratory failure
Acute respiratory failure is classified as an MCC because it significantly increases hospital resource consumption and affects DRG assignment and reimbursement.
Question 7: A patient is treated for cellulitis of the right lower leg. The ICD-10-CM code should specify:
- Only that cellulitis is present, without site specificity
- The specific site and laterality of the cellulitis (Correct answer)
- The causative organism only
- The patient's immune status
Correct answer: The specific site and laterality of the cellulitis
ICD-10-CM requires coding to the highest level of specificity, including the anatomical site and laterality when documented.
CRCR Charge Capture and Coding 3
When coding outpatient services, which diagnosis should be sequenced first when a definitive diagnosis has not been established?