RHIA Clinical Classification Systems and Coding 2

Question 1

ICD-10-PCS codes differ from ICD-10-CM codes in that they are used to classify what?

Accepted Answer

Inpatient procedures performed in a hospital

Answer

ICD-10-PCS (Procedure Coding System) is used exclusively to code inpatient procedures performed in hospital settings, while ICD-10-CM is used for diagnoses.

Question 2

A Present on Admission (POA) indicator of 'N' means the condition was:

Accepted Answer

Not present at the time of inpatient admission

Answer

POA indicator 'N' (No) signifies that the condition was not present at the time of admission and developed during the inpatient stay.

Question 3

In the MS-DRG system, a Major Complication or Comorbidity (MCC) does what compared to a CC?

Accepted Answer

Typically results in higher reimbursement than a CC

Answer

MCCs represent the highest severity of illness and resource use among secondary diagnoses, resulting in higher DRG relative weights and reimbursement compared to CCs.

Question 4

When should a coder initiate a physician query?

Accepted Answer

When clinical indicators suggest a diagnosis that is not documented

Answer

Queries should be generated when clinical indicators in the record support a diagnosis that the physician has not explicitly documented, to ensure complete and accurate coding.

Question 5

Which outpatient coding guideline states that uncertain diagnoses (e.g., 'possible,' 'probable') should NOT be coded?

Accepted Answer

ICD-10-CM Official Guidelines for outpatient coding

Answer

Per the ICD-10-CM Official Guidelines, outpatient/physician coders should report conditions to the highest degree of certainty and not code uncertain or probable diagnoses.

RHIA Exam Practice Test

RHIA Exam Practice Test

RHIA Clinical Classification Systems and Coding 2