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

Correct Answer: Situational; required when a procedure was performed

FL 74, Principal Procedure Code and Date, is situational. It is required on inpatient claims when a procedure was performed, and it is not used on outpatient claims. Option b is incorrect because external cause of injury codes belong to FL 72, which is not used, while FL 74 reports the principal procedure. Option c is incorrect because that description fits reserved or unused locators such as FL 73 and FL 75, whereas FL 74 carries the principal procedure code and date. Option d is incorrect because FL 74 is not used on outpatient claims, so reporting it there is not a requirement and the field belongs to inpatient billing.

Correct Answer: W – Clinically undetermined

The POA reporting definitions assign W when the provider is unable to clinically determine whether the condition was present on admission or not. U is reserved for insufficient documentation, which is a different situation. Option a is incorrect because it applies when documentation is insufficient to determine presence on admission, which is a documentation gap rather than the provider's clinical inability to decide. Option c is incorrect because it marks codes exempt from POA reporting, so no indicator is submitted, which differs from reporting an undetermined status. Option d is incorrect because it states the condition was not present at the time of inpatient admission, a definite finding rather than an undetermined one.

Correct Answer: The instructions and conventions of the classification

The guidelines state that the instructions and conventions of the classification take precedence over guidelines. The guidelines accompany and complement the classification and are based on its Tables, Index and Definitions. Option b is incorrect because the guidelines are a companion document that accompanies and complements the classification, and they are ranked below its instructions and conventions. Option c is incorrect because unique circumstances are described only as situations where exceptions to the guidelines may be applied, not as an authority that outranks the classification. Option d is incorrect because the four Cooperating Parties approved the guidelines, but that approval is not described as placing anything above the instructions and conventions of the classification.

Correct Answer: Obstetrics section, Products of Conception, Retained

Guideline C2 states that curettage of the endometrium or evacuation of retained products of conception following a delivery or abortion is coded in the Obstetrics section, to the root operation Extraction and the body part Products of Conception, Retained. Option a is incorrect because this pairs the right body part with the wrong section, since the guidelines place procedures following delivery or abortion for evacuation of retained products in Obstetrics. Option b is incorrect because the guidelines assign the Endometrium body part in Medical and Surgical to dilation and curettage done outside the postpartum or post-abortion period, which does not fit this timing. Option c is incorrect because the guidelines name the body part for evacuation after delivery as Products of Conception, Retained; the plain Products of Conception body part is the example given for amniocentesis.

Correct Answer: Section X codes require an additional code from another section to complete the procedure.

The New Technology guidelines state that section X codes fully represent the specific procedure in the code title and do not require additional codes from other sections of ICD-10-PCS, so requiring an extra code contradicts them. Option a is incorrect because this restates the New Technology guideline directly: a section X code title fully represents the specific procedure it describes, so the statement is consistent with the guidelines. Option b is incorrect because the guidelines give exactly this instruction, since a fully described procedure that is the only one performed needs no added code from another section. Option d is incorrect because the guidelines send multiple-procedure cases in section X to the multiple procedures guideline, so this statement matches the rule and is not the exception.

Correct Answer: Assign the root operation without a query

The coder is responsible for equating the documentation to defined PCS terms. When the correlation is clear, as with partial resection and the root operation Excision, no physician query is required. Option a is incorrect because the physician is not expected to use PCS code description terms, and a query is unnecessary when the documentation clearly correlates to a defined term. Option b is incorrect because the conventions state the Index need not be consulted first, since a valid code may be chosen directly from the tables. Option c is incorrect because a valid code requires all seven characters to be specified, so skipping a character would leave the code invalid.

Correct Answer: I, II, and III

Guideline B2.1a places chest tube drainage of the pleural cavity in Anatomical Regions, General, and foot amputation in Anatomical Regions, Lower Extremities. Guideline B2.1b defines "upper" as above the diaphragm, while "lower" means below it. Option a is incorrect because this pair is accurate but incomplete, because the guideline also defines upper as the location above the diaphragm, which makes Statement III correct too. Option c is incorrect because it includes Statement IV, but the guideline sets the dividing line for lower at the diaphragm, and Statement I is wrongly left out. Option d is incorrect because Statement IV fails because lower body parts lie below the diaphragm, and this choice also omits Statement II, the foot amputation example.

Correct Answer: A separate procedure for each joint with a different device

Guideline B3.10b states that when multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that uses a different device and/or qualifier. Different devices on two lumbar joints therefore require two procedures. Option b is incorrect because the guideline assigns the Interbody Fusion Device value only to a joint rendered immobile with an interbody fusion device, and the second joint used a different device. Option c is incorrect because the guideline requires a separate procedure for each vertebral joint with a different device or qualifier, so combining both joints under a multiple-joint value is not permitted here. Option d is incorrect because that body part value is a distinct option in the lumbar level, and nothing in the guideline lets it replace separate reporting of two joints with different devices.

Correct Answer: Drainage device placed in a separate procedure

Sutures, ligatures, radiological markers and temporary post-operative wound drains are integral and not coded as devices. A separate procedure to put in a drainage device is coded to the root operation Drainage with the value Drainage Device. Option a is incorrect because ligatures appear in the same list of integral materials, so they receive no device value and are not reported separately. Option b is incorrect because sutures are named in the guideline as materials integral to the performance of a procedure, so they are not coded as devices. Option c is incorrect because these drains are specifically listed as integral to the procedure, which distinguishes them from a drain placed as its own procedure.

Correct Answer: The diagnostic procedure

The selection of principal procedure guideline states that the procedure most related to the principal diagnosis takes precedence. Here the diagnostic procedure relates to the principal diagnosis, so it is sequenced as principal procedure. Option a is incorrect because approach is not a sequencing criterion in the principal procedure instructions; relation to the principal diagnosis decides which procedure comes first. Option b is incorrect because the guideline gives a specific instruction for this situation rather than leaving sequencing to preference, so the choice is not open. Option d is incorrect because treats only the secondary diagnosis, and the guideline gives precedence to the procedure most related to the principal diagnosis, even when it is not definitive treatment.