AAPC-CIC Certified Inpatient Coder - Set 3 - Part 2

Correct Answer: Only individuals named in the regulation may sign, including a doctor of medicine or osteopathy.

The regulation's limitation on authorization to sign states that a certification or recertification statement may be signed only by the listed individuals, and the first listed is a physician who is a doctor of medicine or osteopathy. Option b is incorrect because the regulation requires a separate signed statement for each certification or recertification, with delayed certifications as the stated exception, and that rule does not change who signs. Option c is incorrect because the verification flexibility applies to procedures and forms, while the regulation limits signing to the listed individuals, not to whoever the hospital selects. Option d is incorrect because on the billing form the provider only certifies that the statements were obtained and are on file; the signed statements themselves remain required.

Correct Answer: Extended stay review

Under the recertification provision, a hospital may choose to have extended stay review by its UR committee take the place of the second and subsequent recertifications for PPS day-outlier cases and outlier cases not subject to PPS. Option a is incorrect because certification is the separate physician statement made early in the stay, and the regulation does not describe it as substituting for later recertifications. Option c is incorrect because cost outlier cases are tied to the hospital's request for cost outlier payment, and the substitution provision does not name this kind of review. Option d is incorrect because diagnostic or clinical categories only allow a hospital to vary the timing of the initial certification within the 12-day period, not replace recertifications.

Correct Answer: Secondary diagnoses

Medicare states that the principal diagnosis, secondary diagnoses, procedures performed, sex, age and discharge status determine MS-DRG assignment. Secondary diagnoses are therefore part of the data set, and they also drive the MCC and CC severity levels. Option a is incorrect because standardized charges are used when setting MS-DRG relative weights, but they are not patient data that determine which MS-DRG a discharge is assigned to. Option b is incorrect because hospital characteristics are not listed among the data that classify a discharge; assignment rests on patient and stay data from the inpatient bill. Option d is incorrect because the 3-day window governs which preadmission outpatient services must be billed on the inpatient claim, and it plays no role in classifying the discharge.

Correct Answer: Average group case cost versus average Medicare case cost

Each MS-DRG is assigned a weight that reflects the average case cost in that group compared to the average Medicare case cost. The same MS-DRG weights are used for operating and capital payment rates. Option b is incorrect because the three severity levels (MCC, CC, non-CC) are based on secondary diagnosis codes, and they define MS-DRG splits rather than the weight itself. Option c is incorrect because up to 25 diagnoses and 25 procedure codes are considered for MS-DRG assignment, which is a grouping limit and says nothing about relative resource cost. Option d is incorrect because CMS reviews MS-DRG classifications annually to reflect changes in treatment patterns and technology, which is a maintenance step, not what a weight measures.

Correct Answer: Request review within 60 days; the intermediary decides

Under the review of DRG assignment provision, a hospital has 60 days after notice of the initial assignment to request review and may submit additional information. The intermediary reviews the request and decides whether a change is appropriate. Option a is incorrect because the regulation provides a formal review request after notice of initial assignment, with additional information submitted as part of that request, not an unprompted resubmission. Option b is incorrect because the annual review adjusts MS-DRG classifications for treatment patterns and technology across groups; it does not decide an individual discharge's assignment. Option c is incorrect because the return of a bill for validation and reverification applies when a surgical procedure is unrelated to the principal diagnosis, not to a hospital-initiated review request.

Correct Answer: The inpatient bill for that discharge

The regulation on assignment of discharges to DRGs requires that each discharge be assigned to a single DRG based on essential data abstracted from the inpatient bill for that discharge. Option a is incorrect because services furnished under arrangements concern how the hospital provides covered care, which has no role in supplying data for DRG assignment. Option c is incorrect because the regulation ties classification to data about the particular discharge being classified, not to claims from earlier periods. Option d is incorrect because cost reporting is a separate recordkeeping requirement for participating hospitals under the regulation, and it is not the data source named for assigning a discharge to a DRG.

Correct Answer: Its customary charges for those items and services

Under the inpatient notice and charging rules, a hospital may charge the beneficiary its customary charges for noncovered items and services on outlier days denied because the beneficiary is not entitled to Part A or has exhausted benefits. Option a is incorrect because the differential applies to a private room or luxury service furnished for personal comfort at the beneficiary's request, which is a different situation from denied outlier days. Option b is incorrect because the regulation expressly permits charging the beneficiary on outlier days denied for nonentitlement to Part A or exhausted benefits, so a complete bar does not apply. Option d is incorrect because that rate is the benchmark that caps a private room differential, not the measure for noncovered items and services on denied outlier days.

Correct Answer: The complication

For an admission from outpatient surgery at the same hospital, a complication documented as the reason for the inpatient admission is assigned as the principal diagnosis, consistent with the circumstances of admission governing selection. Option b is incorrect because the admitting diagnosis is the condition identified at the time of admission, a separate claim item that does not decide principal diagnosis selection here. Option c is incorrect because symptom and sign codes are not used as principal diagnosis once a related definitive diagnosis is established, and a documented complication is definitive. Option d is incorrect because the guideline assigns the surgery reason only when no complication or other condition is documented as the reason for the inpatient admission.

Correct Answer: As if both were confirmed

When two or more contrasting or comparative diagnoses are documented as "either/or," they are coded as if confirmed. They are sequenced by the circumstances of the admission, and either may be first if no determination can be made. Option a is incorrect because the guideline that once addressed a symptom followed by contrasting diagnoses was deleted, and the either/or rule has the diagnoses themselves coded. Option b is incorrect because the guideline has both diagnoses coded, and order of documentation does not decide sequencing; the circumstances of the admission do. Option d is incorrect because severity is not the test in the guideline, which codes both conditions and sequences them by the circumstances of the admission.

Correct Answer: The unrelated condition

Under the guideline for admission from outpatient surgery, when the reason for the inpatient admission is another condition unrelated to the surgery, the coder assigns that unrelated condition as the principal diagnosis. Option a is incorrect because this rule governs admissions whose purpose is rehabilitation, which is a different section of the guidelines and not the circumstance described in this scenario. Option c is incorrect because guidelines assign a complication as principal only when that complication occasioned the admission, but the provider here documented a condition with no link to the procedure. Option d is incorrect because it becomes principal only when no complication or other condition is documented as the reason for admission, and here another condition is documented.

Correct Answer: Not Required

The Medicare manual lists Admission Hour as Not Required and states that if the data is submitted, it will be ignored. This differs from the required admission date. Option a is incorrect because the admission hour is not a mandatory entry, and the guidance says submitted data is ignored rather than processed. Option b is incorrect because that status belongs to the admission or start of care date, which the hospital must enter on every inpatient bill. Option d is incorrect because a situational status describes items like condition codes entered only when they apply, not a field whose data CMS disregards.

Correct Answer: Statement Covers Period (From-Through)

FL 6, Statement Covers Period (From-Through), is required and holds the beginning and ending dates of the period included on the bill, entered in numeric MMDDYY fields. Option a is incorrect because it records the month, day and year of birth in an eight-digit format, with zeros entered if the full date is unknown. Option b is incorrect because it holds one date, the date the patient was admitted for inpatient care, not a beginning and ending pair for the bill. Option c is incorrect because it carries a code showing the patient's status as of the Through date of the billing period, not the dates themselves.

Correct Answer: FL 77 - Operating Provider Name and Identifiers

FL 77, Operating Provider Name and Identifiers, is required when a surgical procedure code is listed on the claim. It reports the individual with primary responsibility for performing the surgical procedure(s). Option b is incorrect because this locator is for situational remarks, such as rental details for DME billings or special Medicare secondary payer information, and not for provider names. Option c is incorrect because these locators hold the person matching a qualifier category, such as referring, other operating or rendering provider, rather than the primary surgeon. Option d is incorrect because the attending provider is the individual with overall responsibility for the patient's medical care and treatment on the claim, not the one who performs the surgery.

Correct Answer: Incorrect assignment of a Diagnosis Related Group

Entering any diagnosis other than the principal diagnosis may lead to incorrect assignment of a Diagnosis Related Group, which causes the hospital to be paid incorrectly under PPS, even when another condition is more severe. Option a is incorrect because the version qualifier is a separate required field, and the guidance does not link a substituted diagnosis to a missing qualifier. Option c is incorrect because ignored data applies to unused locators, such as the prospective payment system code field, not to the principal diagnosis field, which is required. Option d is incorrect because the guidance prohibits filling a short code with zeros, so zero-filling is not a consequence of entering another diagnosis.

Correct Answer: Chargemaster

Under the hospital price transparency definitions, the chargemaster (Charge Description Master or CDM) is the list of all individual items and services maintained by a hospital for which the hospital has established a charge. Option a is incorrect because CMS makes this CSV format or JSON schema available so hospitals can comply with reporting requirements; it does not list a hospital's charges itself. Option b is incorrect because it is the highest charge a hospital has negotiated with all third party payers for one item or service, not a list. Option d is incorrect because a single charge applying to an individual who pays cash or a cash equivalent, so it is one price rather than the full list.

Correct Answer: Noncovered Charges

The Noncovered Charges form locator is where the total non-covered charges pertaining to the related revenue code on the claim are entered. It is a required field, tied to the revenue code line. Option a is incorrect because it names the primary, secondary or tertiary payer, such as entering Medicare on line A, and carries no charge amounts at all. Option b is incorrect because it holds the line item date of service for each iteration of a revenue code, not a total of charges the payer will not cover. Option c is incorrect because it is not used, and any data entered there is ignored, so a noncovered total placed there would never be read.

Correct Answer: To keep bill data consistent with the cost report

CMS policy requires providers to bill Medicare on the same basis as other payers so that bill data stays consistent with the cost report and can be used to substantiate that cost report. Option a is incorrect because adjusting interim payment rates to exclude hospital-based physician services is something the A/B MAC does when gross billing is used, not the purpose of this policy. Option b is incorrect because the grand total is carried by the last revenue code entered, and it is a way of reporting charges rather than the reason for the same-basis policy. Option d is incorrect because the guidance addresses consistent treatment of the professional component across payers, either included or excluded; it does not call for removing it from every claim.

Correct Answer: The patient and caregivers/support person(s)

The discharge planning condition of participation requires an effective process focused on the patient's goals and treatment preferences, and it includes the patient and his or her caregivers/support person(s) as active partners in planning post-discharge care. Option b is incorrect because the guidance names no receiving facility as an active partner; the partners it identifies are the patient and the people supporting him or her. Option c is incorrect because the standard centers the process on the patient and his or her caregivers/support person(s), not on a single practitioner acting alone. Option d is incorrect because the UR committee reviews extended stays and professional services for medical necessity, a separate condition-of-participation function, and is not named as the active partner in discharge planning.

Correct Answer: Days before the designation are paid separately as acute care

When an acute care hospital becomes a LTCH during a patient's hospitalization, Medicare treats all days, before and after designation, as one episode of LTCH care and pays the entire stay under one set of requirements, not separately. Option a is incorrect because the regulation states that Medicare considers all days of the stay in the facility to be one single episode of LTCH care. Option b is incorrect because the regulation directs that payment for the entire patient stay, before and after designation, is made under one specified requirement. Option c is incorrect because the regulation counts days both prior to and after the designation of LTCH status within the single episode, so later days are included.

Correct Answer: Readmission on the same day

Under the Medicare regulation on acute care transfers, a discharge is considered a transfer when the patient is readmitted the same day to another hospital of a listed type, which includes a critical access hospital. Option a is incorrect because formal release is simply the discharge definition; a transfer also needs readmission to another hospital of a listed type on the same day. Option b is incorrect because a patient who dies in the hospital is considered discharged under the discharge definition, and cannot be readmitted to another hospital. Option d is incorrect because 3 days is the statutory payment window for diagnostic and related services before admission, not the readmission timing the transfer regulation uses.