CCDS Official Coding Guidelines and Regulatory Compliance 2

Question 1

Under ICD-10-CM Official Guidelines, the 'Excludes1' note indicates:

Accepted Answer

The two conditions cannot occur simultaneously and cannot be coded together

Answer

An Excludes1 note indicates a pure exclusion. The two conditions are mutually exclusive and cannot coexist in the same patient. Therefore they cannot be coded together.

Question 2

Which federal agency is responsible for maintaining and updating the ICD-10-CM code set?

Accepted Answer

CMS and the National Center for Health Statistics (NCHS)

Answer

ICD-10-CM is maintained jointly by CMS and the National Center for Health Statistics (NCHS), a division of the CDC. CMS maintains ICD-10-PCS for the procedural code set used in inpatient settings.

Question 3

A hospital's internal audit reveals that coders have been assigning a CC-designated secondary diagnosis code that is not clinically supported by physician documentation but is mentioned in nursing notes. This practice violates which standard?

Accepted Answer

ICD-10-CM coding guideline requiring physician documentation to support diagnoses

Answer

ICD-10-CM Official Guidelines require that diagnoses be documented by the attending physician or other qualified provider, not nursing staff. Using nursing notes alone to assign a secondary diagnosis code violates coding guidelines.

Question 4

Which OIG program provides annual guidance on high-risk healthcare compliance areas including CDI and coding?

Accepted Answer

OIG Work Plan and annual compliance program guidance

Answer

The OIG Work Plan, published annually, identifies high-risk areas for fraud and abuse including CDI-related issues such as inpatient admission criteria, DRG upcoding, and specific diagnosis documentation.

Question 5

Under the Cooperating Parties coding guidelines, which organization provides the official publication for ICD-10-CM/PCS coding advice?

Accepted Answer

AHA Coding Clinic for ICD-10-CM/PCS

Answer

AHA Coding Clinic for ICD-10-CM/PCS is the official publication for coding guidance, published by the American Hospital Association under the authority of the Cooperating Parties (CMS, NCHS, AHA, AHIMA).

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Official Coding Guidelines and Regulatory Compliance 2