AAPC-COC Certified Outpatient Coder - Set 2 - Part 2

Correct Answer: Minor calyx

A minor calyx surrounds the renal papillae of each pyramid and collects urine from that pyramid. Several minor calyces then converge to form a major calyx, which drains into the renal pelvis. Option a is incorrect because a renal column is a portion of renal cortex extending between adjacent pyramids; it is functional tissue, not a urine-collecting cup. Option b is incorrect because the renal pelvis is the large central cavity in the renal sinus that receives urine from the major calyces and continues into the ureter. Option d is incorrect because this double-layered epithelial cup surrounds the glomerulus within the renal corpuscle of a nephron, so it lies in the cortex and not at the papillae.

Correct Answer: Corpus spongiosum

The corpus spongiosum is the single, midline ventral column of erectile tissue. It surrounds the urethra, which runs its full length, and it expands distally to form the glans penis. Option b is incorrect because this is the part that attaches the penis to the pubic arch, so it names a region, not the urethral column. Option c is incorrect because this is a loose fold of skin, also called the foreskin, that covers the glans penis rather than a column of erectile tissue. Option d is incorrect because they are the two dorsal columns of erectile tissue, not the single midline ventral column that surrounds the urethra.

Correct Answer: Lactiferous duct

A lactiferous duct collects milk from the lobules within each lobe and carries it to the nipple. Each duct enlarges into a lactiferous sinus before the nipple and then opens independently on the nipple surface. Option a is incorrect because is the circular pigmented area surrounding the nipple on the external breast; it does not collect or carry milk from lobules. Option b is incorrect because is the enlarged section of the duct just before the nipple that serves as a milk reservoir, not the collecting and carrying duct. Option c is incorrect because is a band of connective tissue that extends from the skin to the underlying muscles and supports the breast, not a milk channel.

Correct Answer: Placenta

The placenta forms from blood vessels during the embryonic stage, connects the fetus to the uterus, supplies nourishment and gas exchange, and acts as a temporary endocrine gland secreting human chorionic gonadotropin. Option a is incorrect because it forms along the back of the embryo about 22 days after conception and develops into the spinal cord and brain. Option b is incorrect because it lines the stomach and produces gastrin in response to food, so it belongs to digestion rather than pregnancy. Option d is incorrect because it carries oxygen and nutrients between the placenta and the embryo, but it is the route of transport, not the endocrine structure attached to the uterus.

Correct Answer: I and III

Section I contains the classification structure and conventions, general guidelines and chapter-specific guidelines, and Section III covers reporting additional diagnoses in non-outpatient settings. Section II is for principal diagnosis selection, and all sections must be reviewed. Option b is incorrect because statement II misplaces outpatient coding and reporting, which belongs to Section IV; Section II deals with principal diagnosis selection for non-outpatient settings. Option c is incorrect because both statements fail: Section II is not the outpatient section, and the guidelines call for review of all sections to code properly. Option d is incorrect because it adds statement IV, yet the guidelines say all sections must be reviewed to fully understand the rules and instructions needed.

Correct Answer: Legal accountability for establishing the patient's diagnosis

The guidelines use 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 criterion, not job title or employer. Option a is incorrect because the term covers a physician or any qualified health care practitioner, so a physician degree is not required to meet the definition. Option c is incorrect because code assignment is the coder's role, and the guidelines describe the provider and the coder as partners with separate tasks in documentation and reporting. Option d is incorrect because the guidelines define provider by a practitioner's accountability for the diagnosis, and they say nothing that ties the term to who employs the practitioner.

Correct Answer: Includes note

An Includes note appears immediately under a three-character code title. Its purpose is to further define, or give examples of, the content of the category, as the ICD-10-CM conventions describe. Option a is incorrect because it is a pure excludes note meaning "NOT CODED HERE!" and bars use of the excluded code together with the code above it. Option b is incorrect because it stands for "Not elsewhere classifiable" and marks an "other specified" code instead of defining the content of a category. Option c is incorrect because they are a list of terms included under some codes, naming conditions for which that code is used, rather than a note under a category title.

Correct Answer: Assign the default code

The code listed next to a main term in the Alphabetic Index is the default code. When a condition is documented without further information such as acute or chronic, the default code should be assigned. Option a is incorrect because acuity must be documented by the provider; the coder cannot assume it when the record offers nothing beyond the bare condition. Option c is incorrect because a query is directed to conflicting documentation, and code assignment rests on the provider's diagnostic statement rather than on the criteria behind it. Option d is incorrect because "other specified" codes are for documentation that gives detail for which no specific code exists, and this record gives no added detail at all.

Correct Answer: Either "and" or "or"

The ICD-10-CM convention for "and" states that the word is interpreted to mean either "and" or "or" when it appears in a title, so a joints-only condition can still be classified to a "bones and joints" title. Option b is incorrect because that meaning belongs to the word "with" or "in" in a code title, the Alphabetic Index, or a Tabular List note, not to "and." Option c is incorrect because this phrase is the causal reading given to "with" or "in," which presumes a relationship between two conditions; "and" carries no such presumption. Option d is incorrect because the convention does not limit the word to its joining meaning; a condition of bones alone or joints alone still falls in such a title.

Correct Answer: The acute (subacute) code

Under the Acute and Chronic Conditions guideline, when separate subentries exist in the Alphabetic Index at the same indentation level, both conditions are coded and the acute (subacute) code is sequenced first. Option a is incorrect because a sequela is the residual effect after the acute phase has ended, so it does not describe a condition documented as acute and chronic. Option b is incorrect because a combination code classifies two diagnoses or a diagnosis with a manifestation or complication; the acute and chronic guideline calls for coding both separately. Option d is incorrect because the guideline directs that both codes be assigned but places the chronic code after the acute (subacute) code, not ahead of it.

Correct Answer: When no definitive diagnosis is established by the end of the encounter

Under the guideline on use of sign/symptom/unspecified codes, if a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report sign and/or symptom codes in lieu of a definitive diagnosis. Option a is incorrect because a borderline diagnosis is coded as confirmed unless the classification provides a specific entry, so it does not call for symptom codes. Option c is incorrect because signs and symptoms routinely associated with a disease process are not assigned as additional codes unless the classification instructs otherwise. Option d is incorrect because patient refusal is not a condition the guidelines set; they link symptom reporting to whether a definitive diagnosis exists, not to testing decisions.

Correct Answer: It lacks the full number of required characters

Under Section I.B.2, Level of Detail in Coding, a code is invalid if it has not been coded to the full number of characters required, including the 7th character when applicable. Option a is incorrect because that note only signals two codes may be needed to describe a condition and gives no sequencing direction, so it has no bearing on validity. Option b is incorrect because a default code is simply the code listed next to a main term, representing the most common or unspecified condition, and is assigned when no further detail is documented. Option c is incorrect because the guidelines describe unspecified codes as acceptable, even necessary, when clinical information is not sufficient to assign a more specific code.

Correct Answer: Sequence the condition that occasioned the admission after study

Guideline II.F, original treatment plan not carried out, directs the coder to sequence as principal diagnosis the condition that, after study, occasioned the admission, even though treatment was not carried out due to unforeseen circumstances. Option a is incorrect because this applies to two or more interrelated conditions that potentially meet the definition, not to an admission whose planned treatment was simply not carried out. Option b is incorrect because symptom, sign and ill-defined condition codes are not used as principal diagnosis once a related definitive diagnosis has been established, as it was here. Option d is incorrect because the guideline ties principal diagnosis to the reason for admission after study, so the absence of treatment does not shift sequencing to another condition.

Correct Answer: the medical condition that led to the hospital admission

For admission following medical observation, the guideline directs that the principal diagnosis is the medical condition which led to the hospital admission, because it worsened or did not improve and prompted the inpatient stay. Option b is incorrect because symptom codes are not used as principal diagnosis when a related definitive diagnosis has been established, so a presenting symptom does not take that position. Option c is incorrect because free choice of sequencing applies to interrelated conditions that equally meet the definition, and here the guideline names one specific condition. Option d is incorrect because that rule belongs to admission from outpatient surgery when no complication or other condition is documented, not to admission following medical observation.

Correct Answer: Previously treated condition that no longer exists

The outpatient guidelines state not to code conditions that were previously treated and no longer exist. Only coexisting conditions that require or affect care, treatment or management, and qualifying chronic or history conditions, are reported. Option a is incorrect because conditions that coexist at the time of the encounter and require or affect care, treatment or management are to be coded. Option b is incorrect because history codes, including family history, may serve as secondary codes when the historical or family condition affects current care or influences treatment. Option c is incorrect because the guidelines allow chronic diseases receiving ongoing treatment to be coded and reported as many times as the patient receives care for them.

Correct Answer: Reason for the surgery

Under the outpatient surgery guideline, the reason for the surgery is coded as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication. Option a is incorrect because the outpatient surgery guideline names the reason for the surgery as the first-listed diagnosis and gives the contraindication no sequencing role for this encounter. Option c is incorrect because a symptom may be first-listed when a diagnosis has not been established, but here the reason for the surgery is available and takes that position. Option d is incorrect because chronic diseases may be coded as often as they are treated, yet the guideline puts them after the reason for the encounter, as additional diagnoses.

Correct Answer: W – Clinically undetermined

The POA reporting definition for W applies when the provider is unable to clinically determine whether the condition was present on admission or not. The indicator is titled Clinically undetermined. Option b is incorrect because it states the condition was not present at the time of inpatient admission, which is a definite determination the provider did not make here. Option c is incorrect because it is used when documentation is insufficient to determine presence on admission, not when the provider is unable to make that clinical determination. Option d is incorrect because it marks diagnoses exempt from POA reporting, so it does not describe a reportable condition whose timing the provider cannot establish.

Correct Answer: Query the provider for clarification

When documentation is unclear at the time of code assignment as to whether a condition was present on admission, the POA guidelines state that it is appropriate to query the provider for clarification. Option a is incorrect because the POA guidelines are not a substitute for the provider's clinical judgment, and unclear documentation must still be resolved by the provider. Option b is incorrect because coding depends on the official guidelines and UHDDS definitions, not on whether POA status is clear; an unclear status does not remove a reportable condition. Option d is incorrect because Y means the condition was present at the time of inpatient admission, and the guidelines do not allow assuming it when documentation is unclear.

Correct Answer: It is usually necessary to complete the comprehensive service.

NCCI lists three general principles for component services. One is that the component service is usually necessary to complete the comprehensive service. Such a service is integral and therefore not separately reportable. Option a is incorrect because having its own code does not change the result; the Column Two component code is still not separately reportable with the Column One code. Option b is incorrect because NCCI states the reverse: a component service is not a separately distinguishable procedure when performed with the comprehensive service. Option c is incorrect because the guidance describes a component service as an accepted standard of care when the comprehensive service is performed, not as a departure from it.

Correct Answer: Performed after the patient is released from postoperative care

Preparation and monitoring are not separately reportable when performed in association with anesthesia. If the anesthesia provider performs them before and unrelated to the anesthesia, or after release from the anesthesia practitioner's postoperative care, they may be reported with modifiers. Option a is incorrect because services performed in association with the anesthesia service are bundled into it, which is the very situation in which separate reporting is not allowed. Option c is incorrect because sedative or local anesthesia given by the physician performing the procedure is listed as integral to that procedure, so it creates no separate reporting. Option d is incorrect because NCCI states preparation and monitoring are not separately reportable regardless of the mode of anesthesia, so general anesthesia gives no exception.