AAPC-COC Certified Outpatient Coder - Set 4 - Part 2

Correct Answer: The Cooperating Parties

The guidelines were approved by the four organizations making up the Cooperating Parties: AHA, AHIMA, CMS and NCHS. Only the set of guidelines approved by the Cooperating Parties is official. Option a is incorrect because CMS and NCHS are two departments within DHHS that provide the guidelines, yet approval comes from four organizations, including the AHA and AHIMA, not DHHS alone. Option b is incorrect because HIPAA is a law that requires adherence to the guidelines and adopted the diagnosis codes; it is not an organization that approves them. Option c is incorrect because the World Health Organization publishes the ICD-10 statistical classification on which ICD-10-CM is based, but it is not named as the approving body of the guidelines.

Correct Answer: Part B-only plans

The manual lists CCPs, MSA plans and PFFS plans as the three basic MA plan types. Part B-only plans are one of two other types characterized by special enrollment, restricted to beneficiaries who have only Part B. Option a is incorrect because these appear in the manual's list of three basic MA plan types, alongside CCPs and PFFS plans, and are therefore a member of the set. Option c is incorrect because the manual names CCPs first among the three basic types of MA plans, so they belong to the set the stem describes. Option d is incorrect because the manual lists them as the third basic type of MA plan, so they cannot be the odd one out here.

Correct Answer: Reason for the surgery

Section IV states that when a patient presents for outpatient surgery and develops complications requiring admission to observation, the reason for the surgery is the first reported diagnosis, followed by the complications as secondary diagnoses. Option a is incorrect because chronic conditions may be sequenced as additional diagnoses in other encounter types, but they do not serve as the reason for this encounter. Option b is incorrect because complications are reported after the first diagnosis, as secondary diagnoses, according to Section IV guidance for observation following outpatient surgery. Option d is incorrect because this is an inpatient term; in the outpatient setting the term first-listed diagnosis is used in lieu of it.

Correct Answer: Waiver of rights

The Waiver of rights standard states that a covered entity may not require individuals to waive their rights under the complaint provision or the Privacy Rule as a condition of treatment, payment, enrollment, or eligibility for benefits. Option a is incorrect because it requires a covered entity to document sanctions applied to workforce members, which is a recordkeeping duty unrelated to conditioning treatment on a waiver. Option b is incorrect because it addresses how a covered entity must revise its policies when requirements change, not whether individuals may be asked to give up rights. Option c is incorrect because it applies after a known use or disclosure of protected health information violates the rules, requiring reduction of harm, and does not govern intake forms.

Correct Answer: Payment may not be made for failure to file a proper claim

Conditional primary Medicare payments may not be made when the claim is denied for failure to file a proper claim, including timely filing, for any reason other than the beneficiary's physical or mental incapacity. Option a is incorrect because a denial supports conditional payment only when a proper claim was filed; here no proper claim was filed and no incapacity excuses it. Option b is incorrect because secondary benefits depend on a payable claim where the primary plan leaves part of the charge unpaid, which differs from a claim never filed with the GHP. Option d is incorrect because the reimbursement condition applies to conditional payments that are permitted, and this failure to file without incapacity is a listed bar to such payment.

Correct Answer: It applies to all settings, including hospital admissions

The guidelines state that the term encounter is used for all settings, including hospital admissions. The coder therefore reviews the entire record to find the specific reason for the encounter, whether inpatient or outpatient. Option b is incorrect because Sections II and III cover non-outpatient settings, yet the guidelines keep one term across settings rather than swapping in a different word for admissions. Option c is incorrect because Section IV addresses outpatient coding, but the guidelines do not confine the term to that setting; they apply it to hospital admissions as well. Option d is incorrect because the guidelines attach no such meaning to the term; the physician or qualified health care practitioner idea belongs to the separate term provider.

Correct Answer: Health Insurance Portability and Accountability Act (HIPAA)

The guidelines state that adherence when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA), which also adopted the diagnosis codes for all healthcare settings. Option a is incorrect because WHO publishes the ICD-10 on which ICD-10-CM is based, but it is not the U.S. authority requiring adherence to these guidelines. Option c is incorrect because DHHS houses CMS and NCHS, which provide the guidelines, yet the guidance ties the adherence requirement to HIPAA rather than to DHHS itself. Option d is incorrect because the Cooperating Parties are four organizations that approved the guidelines, not a law; they do not create the legal requirement to follow them.

Correct Answer: Report the category when no 7th character is known

For reporting purposes only codes are permissible, not categories or subcategories, and any applicable 7th character is required. Substituting a category when the 7th character is unknown therefore contradicts the convention. Option a is incorrect because a code with an applicable 7th character is considered invalid without it, so including it is a real reporting requirement. Option b is incorrect because the guidelines state the 7th character must always be the 7th character in the data field, so this is a genuine requirement. Option d is incorrect because the guidelines direct that when a code requiring a 7th character has fewer than 6 characters, a placeholder X fills the empty positions.

Correct Answer: Codes

For reporting purposes only codes are permissible, not categories or subcategories. The code is the final level of subdivision, and any applicable 7th character is required for it to be valid. Option b is incorrect because subcategories are the 4- or 5-character levels that come before the final level of subdivision, so they are not permitted for reporting. Option c is incorrect because chapters group the Tabular List by body system or condition, which organizes content but does not make up a reportable level. Option d is incorrect because categories are the 3-character level of the Tabular List, and unless a category has no further subdivision it is not reportable as a code.

Correct Answer: Other specified code

In the Alphabetic Index, NEC, meaning "Not elsewhere classifiable," represents "other specified." Such entries are specific disease entities with no specific code, so the Index directs the coder to the "other specified" code in the Tabular List. Option a is incorrect because unspecified codes are used when the medical record information is insufficient for a more specific code, and NOS, not NEC, is the equivalent of unspecified. Option c is incorrect because the placeholder X only fills empty characters ahead of a required 7th character and has no connection to an NEC entry. Option d is incorrect because manifestation codes belong to etiology/manifestation combinations, which use sequencing notes such as "Code first"; NEC does not point to them.

Correct Answer: Not included here

An Excludes2 note represents "Not included here." The excluded condition is not part of the condition represented by the code, but a patient may have both, so both codes may be reported together when appropriate. Option a is incorrect because it is the meaning given to an Excludes1 note, which is a pure excludes note barring use of both codes together. Option b is incorrect because it is a sequencing instruction placed at the etiology code, and it does not describe how an excluded condition relates to a code. Option c is incorrect because it belongs to the etiology/manifestation convention, where a note directs sequencing of the underlying condition before the manifestation, not an excludes relationship.

Correct Answer: Workers' Compensation Medicare Set-Aside Arrangement

CMS recommends that parties to a WC settlement set aside funds, known as a Workers' Compensation Medicare Set-Aside Arrangement (WCMSA), for future medical and prescription drug services related to the WC injury that Medicare would otherwise reimburse. Option a is incorrect because a waiver forgives a party's obligation to satisfy Medicare's claim in whole or in part when conditions are met, rather than reserving settlement funds for future care. Option b is incorrect because the FELA is not a WC law or plan; the guidance treats it as liability insurance under the MSP liability provisions, not as a settlement protection method. Option d is incorrect because a LGHP is a primary payer for disabled individuals under 65 whose coverage rests on employment with an employer of 100 or more employees, not a settlement tool.

Correct Answer: The situation of the encounter

A "code also" note says two codes may be needed to fully describe a condition, but it gives no sequencing direction. The order depends on the circumstances of the encounter. Option b is incorrect because a default code is the condition most commonly associated with a main term, or the unspecified code, and it does not set order between two codes. Option c is incorrect because the guidelines state that a "code also" note gives no sequencing direction, so the note cannot place either code first. Option d is incorrect because an Excludes1 note means "NOT CODED HERE!" and bars using two codes together, which is the opposite of a "code also" instruction.

Correct Answer: Select the final characters from the Tabular List

A dash at the end of an Alphabetic Index entry means additional characters are required. The full code, including laterality and any 7th character, can only be selected in the Tabular List, so both parts are essential. Option a is incorrect because a default code applies when a condition is documented without further detail, and it does not replace the characters the dash demands. Option c is incorrect because code assignment rests on the provider's diagnostic statement, not on clinical criteria, so a query about criteria does not supply the missing characters. Option d is incorrect because a dash at the end of an entry signals that additional characters are required, so the entry alone is not a complete code.

Correct Answer: Coded when present

The guidelines state that additional signs and symptoms that may not be associated routinely with a disease process should be coded when present, because they are not an integral part of that disease process. Option b is incorrect because unspecified codes are used when clinical information is insufficient for a more specific code, which is a different situation from additional non-integral signs and symptoms. Option c is incorrect because a query is encouraged when documentation is unclear, but the guidelines do not make a query a condition for coding these additional signs and symptoms. Option d is incorrect because omission applies to signs and symptoms routinely associated with a disease process, which are not assigned as additional codes unless the classification instructs otherwise.

Correct Answer: Go to the referenced main term

The ICD-10-CM guidelines state that a "see" instruction following a main term indicates another term should be referenced. It is necessary to go to the referenced main term to locate the correct code. Option a is incorrect because a provider linkage relates to conditions joined by "with" or "in", not to a cross-reference that directs the coder to another term. Option b is incorrect because this describes the optional handling of a "see also" instruction, which may be skipped when the original main term already supplies the necessary code. Option c is incorrect because the "see" instruction signals that the correct code is found elsewhere, so the original main term cannot be relied on for code selection.

Correct Answer: Selecting a specific code the documentation does not support

The guidelines call it inappropriate to select a specific code not supported by the medical record documentation. Each encounter is coded to the level of certainty known for that encounter, so unsupported specificity is not acceptable. Option a is incorrect because the guidelines accept an unspecified code when clinical information is not known or available to assign a more specific one, such as pneumonia without a determined type. Option b is incorrect because the guidelines state that when a definitive diagnosis has not been established by the end of the encounter, reporting sign or symptom codes is appropriate. Option d is incorrect because the guidelines direct that additional signs and symptoms not routinely associated with a disease process should be coded when present.

Correct Answer: When the combination code lacks necessary specificity for the manifestation or complication

The combination code guideline says an additional code should be used as a secondary code when the combination code lacks necessary specificity in describing the manifestation or complication. Otherwise, only the combination code is assigned. Option a is incorrect because the guidelines say multiple coding should not be used if the classification provides a combination code covering every documented element. Option b is incorrect because full identification of the conditions is the very circumstance in which only the combination code is assigned, making any extra code redundant. Option c is incorrect because such a direction means the combination code stands alone, so no secondary code is added under the multiple coding guideline.

Correct Answer: Code the existing underlying condition

When an impending or threatened condition did not occur and the Alphabetic Index has no subterm for impending or threatened, the guidelines direct coding of the existing underlying condition(s), not the impending condition. Option b is incorrect because a query is suggested for unclear borderline documentation, but the impending-condition guideline itself gives a direct coding instruction for this case. Option c is incorrect because confirmed-diagnosis coding applies only when the impending or threatened condition did occur, which is not the situation described here. Option d is incorrect because the guidelines direct coders to the underlying condition, not to an unspecified code, when no subterm for the impending condition is listed.

Correct Answer: Code both as confirmed; either may be sequenced first

Under Section II.D, two or more contrasting or comparative diagnoses documented as "either/or" are coded as if confirmed. When no further determination can be made about which is principal, either diagnosis may be sequenced first. Option a is incorrect because the guideline for sequencing a symptom ahead of contrasting diagnoses was deleted, and the current rule has both diagnoses coded as confirmed. Option c is incorrect because the guideline already covers this situation, allowing either diagnosis to be sequenced first when nothing further shows which should be principal, so no mandatory query step exists. Option d is incorrect because the guideline directs that both contrasting diagnoses be coded, not just the one the provider happened to list first in the documentation.