AAPC-CIC Certified Inpatient Coder - Set 3 - Part 1

Correct Answer: A code with a required 7th character may omit the X when it has fewer than six characters.

The conventions require a placeholder X to fill the empty characters when a code needing a 7th character has fewer than 6 characters. Omitting the X leaves the code invalid, so the statement contradicts the convention. Option a is incorrect because the conventions state exactly this: a 7th character always sits in the 7th position of the data field, so the statement is consistent. Option b is incorrect because the placeholder convention says a code with a placeholder is valid only when the X is used, so this statement agrees with the guidance. Option d is incorrect because the conventions limit reporting to codes, excluding categories and subcategories, so this statement matches the rule instead of contradicting it.

Correct Answer: Injury code with subsequent encounter seventh character

For rehabilitation services following active treatment of an injury, the guidelines direct the coder to assign the injury code with the appropriate seventh character for subsequent encounter as the first-listed or principal diagnosis. Option a is incorrect because that code is sequenced first when the admission is for treating a complication of care, which describes a different circumstance from rehabilitation. Option b is incorrect because the guidelines direct aftercare coding when the treated condition is no longer present, and they expressly exclude rehabilitation that follows an injury. Option c is incorrect because symptom and sign codes are not used as principal diagnosis once a related definitive diagnosis has been established, and rehabilitation of an injury has one.

Correct Answer: Additional characters are required

According to the ICD-10-CM general guidelines on locating a code, a dash at the end of an Alphabetic Index entry indicates that additional characters are required. The full code must then be selected in the Tabular List. Option b is incorrect because a code also note is an instructional notation saying two codes may be required, without sequencing direction; it is not signaled by a dash. Option c is incorrect because a default code is simply the code listed next to a main term, representing the most common or unspecified condition; a dash does not mark it. Option d is incorrect because laterality guidance addresses bilateral conditions separately, and a dash at an Index entry says nothing about whether a bilateral code exists.

Correct Answer: Code it as if it were established

Under Section III.C, a diagnosis documented at discharge as probable, suspected, likely or similar is coded as if it existed or was established. This applies to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals. Option a is incorrect because the guideline already tells the coder what to do with a qualified discharge diagnosis, so no query is required to strip the term probable. Option b is incorrect because that approach reflects outpatient practice for inconclusive diagnoses; the inpatient guideline for these hospital settings directs coding the uncertain condition itself. Option d is incorrect because leaving out a diagnosis qualified as probable at discharge contradicts the inpatient guideline, which directs coding of such conditions rather than waiting for confirmation.

Correct Answer: already

The POA guidelines supplement the official guidelines and apply the indicator to the final set of diagnosis codes assigned under Sections I, II, and III. The indicator is assigned subsequent to code assignment. Option a is incorrect because the guidelines apply the indicator to the final set of diagnosis codes, not to a tentative or interim code list. Option b is incorrect because the guidelines describe code assignment under Sections I, II, and III as the step that precedes the indicator, not as an optional step. Option c is incorrect because the POA guidelines do not govern when a condition is coded; the indicator is applied afterward to the final set of codes.

Correct Answer: It locates the table containing all needed information

The purpose of the Alphabetic Index is to locate the appropriate table that contains all information necessary to construct a procedure code. The PCS Tables are then consulted to build the valid code. Option a is incorrect because the conventions give the construction of a valid code to the PCS Tables, which should always be consulted, so the Index cannot replace them. Option b is incorrect because consulting the Index first is not required, and a valid code may be chosen directly from the tables. Option d is incorrect because defined terms are part of the system itself, and the coder equates documentation to those definitions; the Index only points toward a table.

Correct Answer: The reason for the outpatient surgery

When a patient is admitted after outpatient surgery at the same hospital and no complication or other condition is documented as the reason for admission, the reason for the outpatient surgery is assigned as principal diagnosis. Option a is incorrect because severity does not drive this choice; the guidelines direct the coder to the documented reason for admission or, absent one, the surgery's reason. Option b is incorrect because free choice applies only when diagnoses equally meet the definition, which is a different rule from the outpatient surgery admission guideline. Option c is incorrect because aftercare is directed for rehabilitation admissions when the treated condition is gone, not for inpatient continuation after outpatient surgery.

Correct Answer: Plans for posthospital care, if appropriate

CMS guidance lists three content elements: the reason for inpatient services, the estimated or actual time in the hospital, and the plans for posthospital care, if appropriate. The statement already covers the first two. Option a is incorrect because this applies only to delayed certification statements, where a legitimate reason for delay exists, and is not a standard content element of every certification. Option c is incorrect because the guidance requires a separate signed statement for each certification or recertification, not for each diagnosis, so this is not a content element. Option d is incorrect because the provider certifies on the billing form that statements were obtained and are on file, which is a provider duty rather than certification content.

Correct Answer: A predetermined amount per discharge

Under 42 CFR 412.2(a), both the inpatient operating and inpatient capital-related prospective payment systems pay hospitals a predetermined amount per discharge for inpatient hospital services furnished to Medicare beneficiaries. Option a is incorrect because the target amount was part of a transitional payment formula in the statute for earlier periods, not the basis of payment under the prospective payment systems. Option b is incorrect because regional adjusted DRG rates appeared only in the statute's first transition period; payment is made per discharge, not per cost reporting period. Option c is incorrect because that is a supplemental payment made under subpart F for unusually expensive cases, not the general basis on which hospitals are paid.

Correct Answer: Acquisition costs of kidneys incurred by approved transplant programs

The Medicare regulation on excluded costs lists the acquisition costs of hearts, kidneys, livers, lungs, pancreas and intestines incurred by approved transplant programs as excluded from prospective payment amounts and paid on a reasonable cost basis. Option a is incorrect because routine operating costs are part of the operating costs covered by the prospective payment amount, so they are not carved out for reasonable cost payment. Option b is incorrect because these belong to the definition of operating costs of inpatient hospital services, which the prospective payment amount already pays in full. Option d is incorrect because the capital prospective payment system supplies a payment amount for those periods; only earlier capital-related costs fall under reasonable cost payment.

Correct Answer: I, II, and IV

Children's hospitals must serve inpatients predominantly under age 18, hospitals outside the 50 States, the District of Columbia, or Puerto Rico are excluded, and extended neoplastic disease care hospitals need an average stay over 20 days. Statement III is false. Option a is incorrect because it omits statement IV, which is also accurate because the extended neoplastic disease care hospital classification requires an average inpatient stay greater than 20 days. Option c is incorrect because it includes statement III, but classification changes are made only at the start of a cost reporting period, and it leaves out statement I. Option d is incorrect because it relies on statement III, which misstates the rule that a classification is effective for the entire cost reporting period, and it drops statement II.

Correct Answer: Emergency services furnished by a nonparticipating hospital

The regulation states that inpatient hospital services are not paid under the prospective payment systems when they are emergency services furnished by a nonparticipating hospital. This is one of three listed circumstances, alongside excluded hospitals and certain HMO or CMP arrangements. Option b is incorrect because the exclusion applies to the opposite election, where the HMO or CMP chooses not to have CMS pay the hospital directly. Option c is incorrect because these are bundled onto the inpatient claim under the acute care IPPS payment basis, so they stay inside the system rather than falling outside it. Option d is incorrect because the regulation names a nonparticipating hospital as the exclusion; it gives no such treatment to emergency services at a participating hospital.

Correct Answer: Hospitals occupying space in another hospital's building

A hospital-within-a-hospital is defined by shared space or campus with another hospital and must meet separate criteria for exclusion from the prospective payment systems. It is not among the four special-payment classifications the regulation lists. Option a is incorrect because hospitals reimbursed under State cost control systems approved under the cited part are an enumerated special-provision classification, not an exception to that list. Option c is incorrect because the regulation lists nonparticipating hospitals that furnish emergency services to Medicare beneficiaries as the fourth special-payment classification, so this option is a member of the set. Option d is incorrect because the regulation names these hospitals first among the classifications paid under special provisions, so they belong to the set the stem describes.

Correct Answer: Excluded from the acute care IPPS

Section 1886(d)(1)(B) of the Social Security Act lists inpatient rehabilitation facility hospitals and units among those excluded from the IPPS. Such a hospital is therefore not paid the acute care IPPS per-discharge amount. Option b is incorrect because MS-DRG per-discharge payment describes acute care hospitals under the IPPS, and the statute lists inpatient rehabilitation facility hospitals and units among those excluded. Option c is incorrect because that exclusion applies to hospitals in places such as Guam or American Samoa, which is a location-based category, not a rehabilitation classification. Option d is incorrect because a transfer adjustment applies to postacute care transfers from IPPS hospitals, and an excluded rehabilitation facility is not an IPPS hospital to begin with.

Correct Answer: Not yet an inpatient without a formal order

An individual is an inpatient for Part A payment only if formally admitted pursuant to an order for inpatient admission. Meeting the two-midnight benchmark does not, in itself, make a beneficiary an inpatient. Option a is incorrect because status depends on a formal order for inpatient admission, not on time elapsing, so passing a midnight creates no inpatient status. Option b is incorrect because documented clinical factors support the physician's expectation of two midnights, but they do not replace the order that formally admits the patient. Option c is incorrect because meeting the two-midnight benchmark does not, in itself, make a beneficiary an inpatient; a formal admission order is still required.

Correct Answer: I, III, and IV

The two-midnight benchmark alone does not make a beneficiary an inpatient, and a missing or defective order may be accepted only in extremely rare cases at contractor discretion. Ambiguous language is best clarified before initial billing. Option a is incorrect because statement II is wrong, since an order admitting to Observation defines a non-inpatient service and is not treated as meeting the inpatient admission requirements. Option b is incorrect because it relies on statement II, which is false, and it leaves out statement I, which correctly says the benchmark alone does not create inpatient status. Option d is incorrect because it includes the Observation statement, which is false, and drops statement IV, although CMS advises clarifying ambiguous language before initial billing.

Correct Answer: Length of stay in prior admissions

The regulation bases the physician's expectation on patient history and comorbidities, severity of signs and symptoms, current medical needs, and risk of an adverse event. Length of stay in prior admissions is not among the listed factors. Option b is incorrect because it appears in the regulation's list of complex medical factors supporting the expectation, so it belongs to the set the stem names. Option c is incorrect because the regulation lists it directly among the complex medical factors that form the basis of the physician's expectation of hospital care. Option d is incorrect because the regulation names this factor explicitly as part of the medical basis for expecting hospital care across two midnights.

Correct Answer: countersign

Medicare guidance says the ordering practitioner need not write the order but must authenticate it; for an initial order or a verbal order, authentication takes the form of a countersignature. Option a is incorrect because the ordering practitioner is not required to write the order, so a verbal order does not hinge on that practitioner writing anything. Option c is incorrect because plain signature is the authentication named for a standard written order, while verbal orders call for a different form of authentication by the ordering practitioner. Option d is incorrect because the admission decision cannot be handed to someone lacking state authorization or admitting privileges, so delegation does not authenticate the order.

Correct Answer: Eligibility for Medicare payment

Sections 1814(a)(2) and 1835(a)(2) of the Act make physician certification of the necessity of services a condition for Medicare payment, so a missing certification affects payment eligibility. Option a is incorrect because ordering tests, drugs, and treatments is a physician function described in the regulation's purpose, separate from the payment condition that certification creates. Option b is incorrect because admission decisions belong to the physician's utilization role; certification is a later statement of necessity and does not govern the decision itself. Option c is incorrect because the physician determines length of stay as part of the physician's role in utilization; it is not what a missing certification changes.

Correct Answer: Written description of the certification time schedule

The regulation requires the hospital to keep available on file a written description that specifies the time schedule for certifications and recertifications and indicates whether utilization review of long-stay cases fulfills the second and subsequent recertification requirement. Option a is incorrect because it is a physician certification tied to inpatient CAH services, a patient-level certification rather than the hospital's own procedural document kept on file. Option b is incorrect because it is an event that sets a certification deadline, no later than the request date or 20 days into the stay, whichever is earlier, not a document. Option d is incorrect because a review like this may, at the hospital's option, take the place of second and subsequent recertifications; the on-file description merely states whether that applies.