Free CCDS Official Coding Guidelines and Regulatory Compliance Questions and Answers 1 — Questions and Answers
Question 1: A patient is admitted with chest pain. After a full workup, myocardial infarction is ruled out, and the physician determines the cause of the chest pain to be gastroesophageal reflux disease (GERD). According to UHDDS guidelines, what is the principal diagnosis?
- Acute myocardial infarction
- Chest pain
- Gastroesophageal reflux disease (GERD) (Correct answer)
- Unspecified cardiac condition
Correct answer: Gastroesophageal reflux disease (GERD)
The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. In this case, GERD was the final diagnosis determined to be the cause of the admission.
Question 2: In the inpatient setting, which of the following conditions documented at discharge should be coded as if it existed?
- History of hypertension
- Possible pneumonia (Correct answer)
- Signs of dehydration
- Condition ruled out during the stay
Correct answer: Possible pneumonia
The UHDDS guideline for reporting uncertain diagnoses states that if the diagnosis documented at discharge is qualified as 'probable,' 'suspected,' 'likely,' etc., the condition should be coded as if it existed. This rule applies only to inpatient admissions.
Question 3: What is the primary purpose of the Medicare 'Two-Midnight Rule'?
- To set a maximum length of stay for a given diagnosis.
- To determine if a hospital stay should be paid as inpatient (Part A) or outpatient (Part B). (Correct answer)
- To mandate that all patients must be discharged after two midnights.
- To define the criteria for medical necessity of a surgical procedure.
Correct answer: To determine if a hospital stay should be paid as inpatient (Part A) or outpatient (Part B).
The Two-Midnight Rule is a policy that guides admitting physicians on when to admit a patient as an inpatient. It generally considers a hospital stay spanning two midnights to be appropriate for inpatient payment under Medicare Part A.
Question 4: A CDS identifies conflicting information in the medical record regarding the cause of a patient's anemia. What is the most appropriate action?
- Choose the diagnosis that provides the highest reimbursement.
- Ignore the conflict as it is the coder's responsibility.
- Initiate a physician query for clarification. (Correct answer)
- Make an assumption based on the lab values.
Correct answer: Initiate a physician query for clarification.
The role of a CDS is to ensure documentation is clear, consistent, and complete. When documentation is conflicting or ambiguous, the appropriate action is to initiate a compliant, non-leading physician query to resolve the discrepancy.
Question 5: Which of the following would be considered a reportable secondary diagnosis?
- A family history of colon cancer.
- Chronic hypertension managed with home medications that are continued during the stay. (Correct answer)
- A resolved case of pneumonia from two years ago.
- A condition mentioned in the ED note but not addressed again.
Correct answer: Chronic hypertension managed with home medications that are continued during the stay.
According to UHDDS, a secondary diagnosis is a condition that coexists at admission or develops subsequently, and affects patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, or increased nursing care/monitoring.
Question 6: The Uniform Hospital Discharge Data Set (UHDDS) provides official definitions for which of the following?
- Sepsis-3 clinical criteria
- Hospital-Acquired Conditions (HACs)
- Appropriate use of physician queries
- Principal diagnosis and other diagnoses (Correct answer)
Correct answer: Principal diagnosis and other diagnoses
The UHDDS was established to create a standardized system for collecting hospital data. It provides the core definitions for principal diagnosis, other (secondary) diagnoses, and significant procedures, which are foundational to inpatient coding and reporting.
Free CCDS Official Coding Guidelines and Regulatory Compliance Questions and Answers 1
A patient is admitted with chest pain.
After a full workup, myocardial infarction is ruled out, and the physician determines the cause of the chest pain to be gastroesophageal reflux disease (GERD).
According to UHDDS guidelines, what is the principal diagnosis?