FREE CCDS Official Coding Guidelines and Regulatory Compliance 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?

Accepted Answer

Gastroesophageal reflux disease (GERD)

Answer

Acute myocardial infarction

Answer

Chest pain

Answer

Unspecified cardiac condition

Question 2

In the inpatient setting, which of the following conditions documented at discharge should be coded as if it existed?

Accepted Answer

Possible pneumonia

Answer

History of hypertension

Answer

Signs of dehydration

Answer

Condition ruled out during the stay

Question 3

What is the primary purpose of the Medicare 'Two-Midnight Rule'?

Accepted Answer

To determine if a hospital stay should be paid as inpatient (Part A) or outpatient (Part B).

Answer

To set a maximum length of stay for a given diagnosis.

Answer

To mandate that all patients must be discharged after two midnights.

Answer

To define the criteria for medical necessity of a surgical procedure.

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?

Accepted Answer

Initiate a physician query for clarification.

Answer

Choose the diagnosis that provides the highest reimbursement.

Answer

Ignore the conflict as it is the coder's responsibility.

Answer

Make an assumption based on the lab values.

Question 5

Which of the following would be considered a reportable secondary diagnosis?

Accepted Answer

Chronic hypertension managed with home medications that are continued during the stay.

Answer

A family history of colon cancer.

Answer

A resolved case of pneumonia from two years ago.

Answer

A condition mentioned in the ED note but not addressed again.

Question 6

The Uniform Hospital Discharge Data Set (UHDDS) provides official definitions for which of the following?

Accepted Answer

Principal diagnosis and other diagnoses

Answer

Sepsis-3 clinical criteria

Answer

Hospital-Acquired Conditions (HACs)

Answer

Appropriate use of physician queries