AAPC-CPC Certified Professional Coder - Set 3 - Part 1

Correct Answer: Billing for items or services not rendered

OIG guidance lists billing for items or services not rendered or not provided as claimed as a frequent subject of investigations. Its own example is an ophthalmologist who billed for laser surgery without having laser equipment at the place of service. Option a is incorrect because this risk area concerns misuse of provider identification numbers, but the scenario centers on a service that was never performed, not on an identifier. Option b is incorrect because unbundling is a different bulleted risk area in OIG guidance, and nothing in the scenario involves billing separately for components of a service. Option d is incorrect because double billing means billing the same item or service more than once, and the scenario describes a single claim for a service never performed.

Correct Answer: AHA, AHIMA, CMS and NCHS

Only the set of guidelines approved by the Cooperating Parties is official. The four Cooperating Parties for ICD-10-CM are the AHA, AHIMA, CMS and NCHS, so an unapproved handout carries no official status. Option a is incorrect because WHO publishes the ICD-10 on which ICD-10-CM is based, but it is not one of the four Cooperating Parties. Option b is incorrect because DHHS is the department housing CMS and NCHS, and WHO is not a Cooperating Party, so this group is wrong. Option c is incorrect because these two agencies provide the guidelines, yet approval comes from four organizations, so AHA and AHIMA are missing from this answer.

Correct Answer: Both codes may be reported together, when appropriate

An Excludes2 note means "Not included here." The excluded condition is not part of the condition represented by the code, but a patient may have both, so using both codes together is acceptable when appropriate. Option b is incorrect because sequencing order is set by code first and use additional code notes in the etiology/manifestation convention, not by an Excludes2 note. Option c is incorrect because that restriction describes an Excludes1 note, which marks codes that should not be used at the same time as the code above it. Option d is incorrect because a query is advised only for an Excludes1 note when it is unclear whether the two conditions are related, not for Excludes2.

Correct Answer: Listed after the underlying condition code

Under the etiology/manifestation convention, a code titled "in diseases classified elsewhere" is a manifestation code. It must be used with an underlying condition code and listed following that code, never first. Option a is incorrect because severity does not change the order; the guidelines require the underlying condition first, and these codes are never first listed or principal diagnosis codes. Option b is incorrect because sequencing follows the etiology-then-manifestation order shown by the instructional notes and bracketed Index entries, not alphabetical position, which has no role here. Option d is incorrect because these codes must be used in conjunction with an underlying condition code, so they cannot stand alone as principal or first listed diagnoses.

Correct Answer: Unbundling

NCCI guidance states that a provider shall not report multiple HCPCS/CPT codes when a single code describes the services performed, and it calls this type of unbundling incorrect coding. Option b is incorrect because this is a basic rule requiring the code that describes the procedure as precisely as possible, so it is a correct-coding duty, not an error. Option c is incorrect because this is the principle behind many PTP edits and explains what a code includes; it is a basis for the rule, not the name of the error. Option d is incorrect because this rule says a code is reported only when all the services it describes were performed, which addresses missing services rather than splitting a single code.

Correct Answer: Add the missing characters from the Tabular List

A dash at the end of an Alphabetic Index entry indicates that additional characters are required. The full code, including laterality and any 7th character, can only be selected in the Tabular List. Option a is incorrect because a three-character code is used only when it is not further subdivided, and a dash signals that more characters are required. Option c is incorrect because a default code applies when a condition is documented without further detail, but it does not resolve a dash calling for additional characters. Option d is incorrect because queries are directed at conflicting medical record documentation, while the missing characters are found in the classification itself, not from the provider.

Correct Answer: Nature of the sequela first, sequela code second

Under the ICD-10-CM guidelines for sequela (late effects), the condition or nature of the sequela is sequenced first and the sequela code second, unless the sequela code is followed by a manifestation code or is expanded to include the manifestation. Option b is incorrect because reverses the order; the guidelines place the sequela code in the second position, after the condition or nature of the sequela. Option c is incorrect because the acute phase code is never reported with a code for the late effect, so it has no place in this pair. Option d is incorrect because that describes a "code also" note, which gives no sequencing direction, whereas sequela coding has a fixed order.

Correct Answer: Locate the term in the Alphabetic Index

The general coding guidelines direct the coder to first locate the term in the Alphabetic Index and then verify the code in the Tabular List, reading instructional notations in both. Both parts are essential for assigning a code. Option a is incorrect because symptom codes are acceptable only when no related definitive diagnosis is established, so scanning them cannot be the opening move for a documented diagnosis. Option c is incorrect because the Tabular List is where the code is verified after the Index lookup, and it is also the only place the full code, including laterality and 7th character, is selected. Option d is incorrect because a default code is simply what appears beside a main term in the Index, so it can only be found after that term is located.

Correct Answer: Unspecified codes apply when the record gives detail for which no specific code exists.

The guidelines assign detailed conditions that lack a specific code to "other" or "other specified" codes. "Unspecified" codes are used when the record is insufficient for a more specific code, so the last statement is wrong. Option a is incorrect because it restates the guideline for codes titled "other" or "other specified", so it is an accurate statement and not the exception. Option b is incorrect because insufficient documentation is exactly the condition the guidelines give for using an "unspecified" code, which makes this statement true. Option d is incorrect because the guidelines say NEC entries are specific disease entities with no specific code, so they lead to an "other" code; the statement is true.

Correct Answer: Reported only if hospital policy requires it

Under the previous conditions guideline, resolved conditions and status-post procedures from earlier admissions that have no bearing on the current stay are not reported. They are coded only if hospital policy requires it. Option b is incorrect because W means the provider cannot clinically determine whether a reportable condition was present on admission; it does not apply to a condition that is not reported at all. Option c is incorrect because Chapter 18 holds symptoms, signs and ill-defined conditions, which are a separate category and say nothing about how resolved previous conditions are treated. Option d is incorrect because principal diagnosis is the condition established after study to be chiefly responsible for the admission, and a resolved earlier condition with no bearing on the stay does not meet that definition.

Correct Answer: Code the condition to the highest degree of certainty

Outpatient guidelines do not allow coding of uncertain diagnoses such as "suspected." The coder instead reports the condition to the highest degree of certainty for that encounter, such as a symptom, sign, or abnormal test result. Option a is incorrect because the UHDDS definition of principal diagnosis does not apply to hospital-based outpatient services or provider-based office visits, so it cannot settle this question. Option b is incorrect because the outpatient guidelines prohibit coding diagnoses documented with terms such as "suspected" or "probable"; that practice belongs to inpatient hospital reporting. Option c is incorrect because the guidelines direct coding of symptoms, signs, or abnormal test results for that encounter, recognizing that diagnoses are often not established at the initial visit.

Correct Answer: Code from the pre-procedural examination subcategory

For patients receiving preoperative evaluations only, the guidelines direct that a code from the pre-procedural examination subcategory describing the pre-op consultation is sequenced first. The reason for surgery follows as an additional diagnosis. Option a is incorrect because selecting the more definitive postoperative diagnosis applies to ambulatory surgery encounters, not to an encounter limited to preoperative evaluation. Option c is incorrect because the surgical condition is assigned as an additional diagnosis after the pre-op consultation code, so it is not the first-listed diagnosis. Option d is incorrect because listing a service Z code first is the exception for therapeutic-only encounters whose primary reason is chemotherapy or radiation therapy, not pre-op evaluations.

Correct Answer: Codes that describe symptoms and signs

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting when the provider has not established (confirmed) a related definitive diagnosis. Chapter 18 contains many, but not all, symptom codes. Option a is incorrect because a default code is assigned when a documented condition lacks added detail, such as acute or chronic, not when no diagnosis exists. Option b is incorrect because these are used when the record gives detail for a condition but no specific code exists, so they presume an established condition. Option d is incorrect because these codes cover circumstances other than a disease or injury that are recorded as diagnoses or problems, which does not describe a complaint under evaluation.

Correct Answer: Column Two, not separately reportable with the Column One code

When integral component services have their own HCPCS/CPT codes, NCCI PTP edits place the comprehensive service in Column One and the component service in Column Two. The Column Two code is not separately reportable with the Column One code. Option a is incorrect because Column One is where NCCI places the more comprehensive service, not the integral component, so this reverses the roles of the two services. Option c is incorrect because this has the bundling backward: the component is included in the comprehensive service, and the comprehensive service is never treated as a part of its own component. Option d is incorrect because the column is right, but a component service integral to a comprehensive service is not separately reportable with it, so reporting both is inappropriate.

Correct Answer: Unbundling

NCCI guidance states that a provider shall not report multiple HCPCS/CPT codes when a single code describes the services performed, and it calls this type of unbundling incorrect coding. Option b is incorrect because this rule says a code is reported only when all the services it describes were performed, which addresses missing services rather than splitting a single code. Option c is incorrect because this is the principle behind many PTP edits and explains what a code includes; it is a basis for the rule, not the name of the error. Option d is incorrect because this is a basic rule requiring the code that describes the procedure as precisely as possible, so it is a correct-coding duty, not an error.

Correct Answer: Mutually exclusive procedures

Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter. Repairing an organ by two different methods is the example given, since only one method can be chosen. Option a is incorrect because this concerns a code descriptor containing that term, which bars separate reporting with a related procedure in an anatomically related region, not alternative methods. Option b is incorrect because this rationale applies where the Column Two code is not separately reportable given the nature of the Column One procedure, or the pairing is a coding error. Option c is incorrect because this describes groups of related codes in which the most comprehensive code describing the services performed is reported instead of component codes.

Correct Answer: “List separately in addition to code for primary procedure”

Add-on codes are generally identified by the parenthetical statement “list separately in addition to code for primary procedure.” Some supplemental codes instead are used only with certain primary codes, which are parenthetically identified. Option b is incorrect because unlisted codes sit at the end of each section or subsection and report services that no other code accurately describes. Option c is incorrect because it marks a procedure that is generally included in a more comprehensive procedure and is not billed with a related primary service. Option d is incorrect because component codes in a family are included in a comprehensive code and are not billed separately when the complete procedure is done.

Correct Answer: Omit it as an additional code unless the classification instructs otherwise

Signs and symptoms associated routinely with a disease process are integral to it, so they should not be assigned as additional codes unless the classification instructs otherwise. The definitive diagnosis already describes them. Option a is incorrect because symptom codes are acceptable only when no related definitive diagnosis has been established, and here the provider has already confirmed one. Option b is incorrect because a query is called for when medical record documentation conflicts, which is not the situation described, since the sign is simply integral to the diagnosis. Option c is incorrect because that treatment fits additional signs not routinely associated with the disease process; signs routinely associated with it are not assigned as additional codes.

Correct Answer: Separate billing of each component

When the professional component and the technical component are provided in different enrolled practice locations, Medicare requires each to be billed separately. Applying the same place of service code to both does not allow global billing. Option a is incorrect because this reduction applies when services included in a global surgery package are billed in pieces and total charges exceed the global fee, a different problem. Option b is incorrect because modifier 50 reports bilateral surgery performed on both sides of the body, so it has no role in combining professional and technical components. Option d is incorrect because entering the same place of service code on both components does not permit global billing for any diagnostic procedure, according to Medicare guidance.

Correct Answer: Modifier -22

Medicare guidance allows modifier -22 on a procedure when the services performed are significantly greater than usually required. The biller must supply a concise statement of how the service differs and an operative report with the claim. Option b is incorrect because it reports services significantly less than usually required, so it describes the opposite circumstance from the one in the question. Option c is incorrect because it reports an unrelated procedure by the same physician during a postoperative period and does not describe an increased procedural service. Option d is incorrect because it reports a significant, separately identifiable evaluation and management service on the day of a procedure, not a more extensive surgical service.