AAPC-CDEO Certified Documentation Expert Outpatient - Set 5 - Part 1

Correct Answer: Clinical practice improvement activities

Under the MIPS statute, the Secretary determines the composite performance score using four performance categories: quality, resource use, clinical practice improvement activities, and meaningful use of certified EHR technology. Option b is incorrect because the statute names four categories for the composite performance score, and risk adjustment does not appear on that list of performance categories. Option c is incorrect because the statute's list of performance categories contains no item by this name; resource use is the listed category that addresses cost. Option d is incorrect because the statute lists quality, resource use, clinical practice improvement activities and meaningful use of certified EHR technology, and patient satisfaction surveys is not named among them.

Correct Answer: Ratio of providers to patients

AHRQ lists the ratio of providers to patients as a structural measure. Structural measures show a provider's capacity, systems, and processes to provide high-quality care, alongside examples such as electronic medical records and the proportion of board-certified physicians. Option a is incorrect because testing and controlling blood sugar reflects recommended clinical practice for a diagnosed condition, which places it among process measures rather than measures of capacity. Option b is incorrect because the percentage of patients who died as a result of surgery shows the impact of care on patients' health status, making it an outcome measure. Option c is incorrect because this counts a preventive service delivered to people, which shows what a provider does, so AHRQ classifies it as a process measure.

Correct Answer: relevance

Frameworks like the IOM domains make it easier for consumers to grasp the meaning and relevance of quality measures, because grouped measures show how they relate to consumers' own concerns about their care. Option a is incorrect because cost is not what the framework is said to clarify; the guidance ties domain grouping to meaning and how measures relate to consumer concerns. Option b is incorrect because the framework is described as making measures easier to understand, so it aims to reduce complexity rather than convey it as something consumers grasp. Option d is incorrect because how often a measure is reported is not described as a benefit of the framework; the stated benefit concerns how consumers understand the measures.

Correct Answer: A joint effort between provider and coder

The guidelines state that a joint effort between the healthcare provider and the coder is essential for complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. Option a is incorrect because the guidelines state the reverse: instructions and conventions of the classification take precedence over the guidelines, which only complement them. Option c is incorrect because coder-only work leaves out the provider, who is legally accountable for establishing the diagnosis, so it would not meet the collaboration the guidelines call essential. Option d is incorrect because the guidelines direct that the entire record be reviewed to find the reason for the encounter and conditions treated, not a single statement.

Correct Answer: Any practitioner legally accountable for establishing the patient's diagnosis

The guidelines use the term provider to mean a physician or any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis. Legal accountability for the diagnosis is the defining feature. Option a is incorrect because coders work jointly with the provider, but the guidelines tie the term provider to legal accountability for the diagnosis, not to code assignment. Option b is incorrect because that describes a query professional, a role that can include CDI staff, quality improvement, utilization review and coders, and it is not defined by diagnostic accountability. Option d is incorrect because ancillary professionals contribute relevant documentation as clinical indicators, yet that contribution does not make them legally accountable for establishing the diagnosis.

Correct Answer: They are often used interchangeably for outpatient contacts

The outpatient guidelines state that encounter and visit are often used interchangeably to describe outpatient service contacts, so they appear together without distinguishing one from the other. Encounter is also the term used for all settings. Option a is incorrect because the guidelines treat visit as a counterpart of encounter for outpatient contacts, covering hospital-based outpatient services as well as office visits. Option b is incorrect because the guidelines state that encounter is used for all settings, including hospital admissions, so it is not limited to inpatient stays. Option c is incorrect because the guidelines let both terms appear together without distinguishing one from the other, so no required distinction exists for outpatient contacts.

Correct Answer: The entire record

The ICD-10-CM Official Guidelines state that the entire record should be reviewed to determine the specific reason for the encounter and the conditions treated, because accurate coding depends on consistent, complete documentation. Option a is incorrect because a chief complaint is only one piece of documentation and cannot show every condition treated, so the guidelines call for reviewing more than this element. Option b is incorrect because the guidelines do not limit review to a closing statement; they direct a broader review so the reason for the encounter is determined from complete documentation. Option d is incorrect because relying on a single latest note would miss information elsewhere in the record, whereas the guidelines point the coder to the complete record.

Correct Answer: Down code the service and adjust payment

When the medical record supports a higher or lower level code, Medicare instructions have contractors adjust the code and the payment rather than deny the entire claim. An E&M level billed above what the record supports is an example. Option b is incorrect because the manual directs contractors not to deny the whole claim when the record supports a higher or lower level code. Option c is incorrect because leaving the level as billed ignores the record. Contractors correct the code to match documentation and then adjust the payment accordingly. Option d is incorrect because contractors are told not to swap one item's payment amount for another's on a reasonable and necessary determination; the same service is paid at its supported level.

Correct Answer: Change the code and the payment

When the medical record supports a higher or lower level code, contractors up code or down code, adjusting both the code and the payment. They do not deny the entire claim, because the service actually provided can still be paid. Option a is incorrect because CMS instructions tell contractors not to deny the whole claim when the record supports a higher or lower level code. Option b is incorrect because the record supports a different level, so the instructions call for correcting the code and payment, not accepting the billed code unchanged. Option c is incorrect because contractors are directed not to replace one item's payment with another's on a reasonable and necessary determination; the service actually provided is what gets paid.

Correct Answer: appropriate medical training

OIG guidance lists, as an internal documentation guideline, that the rationale for ordering diagnostic and ancillary services can be easily inferred by an independent reviewer or third party who has appropriate medical training. Option a is incorrect because the claim form is a separate documentation area in the guidance, and familiarity with it is not the stated reviewer qualification. Option b is incorrect because up coding is a contractor payment adjustment when the record supports a higher level, and it has nothing to do with inferring order rationale. Option d is incorrect because claim denial rates are a benchmarking tool for comparing a practice with others in its specialty, not a qualification of the reviewer.

Correct Answer: The patient's insurance eligibility

OIG guidance says the medical record may validate the site of the service, appropriateness of services, accuracy of billing and identity of the care giver. The patient's insurance eligibility is not among the listed items. Option a is incorrect because the guidance lists the identity of the care giver (service provider) as something the medical record can validate, so it is a genuine member. Option c is incorrect because the guidance names billing accuracy among the items the record validates, so it belongs to the set rather than standing apart from it. Option d is incorrect because the guidance includes the site of the service in its list of items the medical record may be used to validate.

Correct Answer: Tabular List

The ICD-10-CM is divided into the Alphabetic Index and the Tabular List. The Tabular List is the structured list of codes divided into chapters based on body system or condition. Option a is incorrect because it is one part of the Alphabetic Index and organizes neoplasm terms, not a chapter-based structured list of codes. Option b is incorrect because it belongs to the Alphabetic Index, which lists terms alphabetically with their corresponding codes rather than grouping codes into chapters. Option d is incorrect because it is a section of the Alphabetic Index that lists external cause terms, so it does not divide codes into chapters.

Correct Answer: I and II

In both the Alphabetic Index and the Tabular List, NEC ("Not elsewhere classifiable") represents "other specified," and NOS ("Not otherwise specified") is the equivalent of unspecified. Statements I and II match the guidelines. Option b is incorrect because statement III is wrong, since NEC is used in both the Alphabetic Index and the Tabular List, each with the same meaning. Option c is incorrect because statement IV is wrong, because NOS is the equivalent of unspecified, while the NEC entry leads to the "other specified" code. Option d is incorrect because it combines two false statements: NEC is not limited to the Tabular List, and NOS does not point to "other specified" codes.

Correct Answer: Assign codes for the documented manifestations

When the Alphabetic Index offers no guidance for a syndrome, the guideline directs the coder to assign codes for the documented manifestations of the syndrome. Option a is incorrect because nothing in the guideline limits reporting to one manifestation; additional manifestations outside the disease process may also be assigned when no unique code exists. Option b is incorrect because the guideline directs coders to the documented manifestations when the Index is silent, and an unspecified code is not named as the fallback. Option d is incorrect because the guidelines do not require the word complication, and this syndrome question concerns manifestations rather than the relationship between care and a condition.

Correct Answer: An "other" or "other specified" code

Codes titled "other" or "other specified" are used when the record gives detail for which no specific code exists. Alphabetic Index entries with NEC designate these "other" codes in the Tabular List. Option a is incorrect because unspecified codes are meant for records whose information is insufficient for a more specific code, but here the record gives specific detail. Option b is incorrect because the placeholder X is a character that allows future expansion at certain codes and does not describe a condition lacking a specific code. Option c is incorrect because an Excludes1 note means "NOT CODED HERE!" and marks conditions that cannot occur together, so it does not direct code selection for NEC entries.

Correct Answer: Additional characters are required

A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. The Index does not always give the full code, so the Tabular List must be used to complete it. Option b is incorrect because a dash signals the opposite, since the entry is incomplete and the Tabular List must supply the remaining characters, such as laterality. Option c is incorrect because a default code is the code listed next to a main term, representing the most common or unspecified condition, not a dash notation. Option d is incorrect because sequencing is not given by a dash; a "code also" note says two codes may be needed yet gives no sequencing direction.

Correct Answer: Reference another main term to locate the code

A "see" instruction following a main term in the Alphabetic Index indicates that another term should be referenced. The coder must go to the referenced main term to locate the correct code. Option a is incorrect because a default code is the code listed next to a main term, representing the most common or unspecified condition, and is not what a "see" instruction directs. Option b is incorrect because that interpretation belongs to the convention for "with" or "in", which presumes a causal relationship between two conditions, not to cross-references. Option d is incorrect because sequencing direction comes from notes such as "code first" or "use additional code"; a "see" instruction only sends the coder to another main term.

Correct Answer: Report a second code as a secondary code

ICD-10-CM guidelines state that when a combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code to supply the missing detail. Option b is incorrect because a sequela is the residual effect after the acute phase has ended, and the documentation does not describe a residual condition. Option c is incorrect because that sequencing rule covers one condition described as both acute and chronic with separate Alphabetic Index subentries, not a combination code lacking detail. Option d is incorrect because that instruction applies when the combination code fully identifies the conditions involved, and here the code lacks the needed specificity.

Correct Answer: Do not use the excluded code at the same time

An Excludes1 note is a pure excludes note meaning "NOT CODED HERE!" The excluded code should not be used at the same time as the code above the note, because the two conditions cannot occur together. Option a is incorrect because a default code applies when a condition is documented without additional information such as acute or chronic, which is not what an Excludes1 note addresses. Option b is incorrect because that describes a "code also" note, which says two codes may be needed and leaves sequencing to the circumstances of the encounter. Option d is incorrect because that is the convention for the word "and" in a title, which concerns how wording is read and not how excluded codes relate.

Correct Answer: Sequencing depends on the circumstances of the encounter

A "code also" note indicates that two codes may be required to fully describe a condition, but it gives no sequencing direction. The order of the codes depends on the circumstances of the encounter. Option a is incorrect because the guideline gives no sequencing direction through this note, so it cannot fix the flagged code in the first position. Option b is incorrect because placing the flagged code last is a sequencing rule, and a "code also" note supplies no such direction either way. Option c is incorrect because that describes an Excludes1 note, which means "NOT CODED HERE!"; a "code also" note says two codes may be required.