AAPC-CPC Certified Professional Coder - Set 4 - Part 1

Correct Answer: It does not mean the condition was not present on admission

The POA guidelines set no required timeframe for a provider to identify or document a condition. A definitive diagnosis may take several days, and that delay does not mean the condition was not present on admission. Option a is incorrect because the unknown indicator is for insufficient documentation, not for a diagnosis made later; the guideline sets no link between diagnostic delay and that indicator. Option c is incorrect because the guideline states that a delay before a definitive diagnosis does not establish that the condition arose after admission. Option d is incorrect because exemption applies to listed codes describing circumstances or conditions always present on admission, not to diagnoses whose confirmation came late.

Correct Answer: Invalid, since a required character is missing

The ICD-10-CM uses the placeholder character X at certain codes to allow for future expansion. Where a placeholder exists, the X must be used for the code to be considered valid, so omitting it makes the code invalid. Option a is incorrect because having the 7th character is necessary but not enough; where an X exists at a code, it must also be used for validity. Option b is incorrect because reporting permits only codes, not categories or subcategories, so relabeling the shortened entry as a subcategory would not make it reportable. Option d is incorrect because the X is there to allow future expansion of the classification, and the guidelines require it wherever it exists, so it cannot be dropped.

Correct Answer: As either "and" or "or"

The ICD-10-CM guidelines state that "and" in a title is interpreted to mean either "and" or "or." Tuberculosis of bones, of joints, or of both therefore classifies to the same subcategory. Option b is incorrect because that meaning belongs to the words "with" and "in", which presume a causal link between two conditions; it is not the rule for "and". Option c is incorrect because the guideline does not limit "and" to its literal meaning in a title; if it did, joint-only disease would fall outside the category. Option d is incorrect because that phrase defines an Excludes2 note, which allows both conditions to be reported together, and has nothing to do with reading "and" in a title.

Correct Answer: Billing for non-covered services as if covered

OIG guidance lists billing for non-covered services as if covered as its own coding and billing risk area. A service can be supported by the patient's condition and still fall outside Medicare coverage, so necessity does not settle coverage. Option a is incorrect because it covers claims for services never provided, such as surgery that was not performed, but in this case the provider actually performed the service. Option b is incorrect because that risk area concerns reimbursement for a service the documented medical condition does not warrant, whereas here the condition supports the service and coverage is the issue. Option d is incorrect because duplicate billing means the same item or service is billed more than once, and nothing here suggests a repeated claim.

Correct Answer: Once per encounter

The Reporting Same Diagnosis Code More than Once guideline states that each unique ICD-10-CM diagnosis code may be reported only once for an encounter. This covers two different conditions classified to the same code. Option a is incorrect because the guideline limits each unique code to a single report per encounter, and it names two different conditions classified to one code as an example of that limit. Option b is incorrect because laterality codes separate left and right sides of one condition; they do not permit a repeat report when two different conditions share one code. Option c is incorrect because separate documentation does not change the limit; each unique diagnosis code is reported only once for an encounter, whatever the number of conditions.

Correct Answer: The existing underlying condition(s)

When a condition described as impending or threatened did not occur and the Alphabetic Index lists no such subterm, the guideline directs coding the existing underlying condition(s), not the threatened condition. Option b is incorrect because symptom codes are acceptable when a related definitive diagnosis is not established, but the guideline for threatened conditions directs coding the existing underlying condition(s) instead. Option c is incorrect because unspecified codes address missing detail such as an unidentified side; they do not replace the instruction to code the underlying condition when no subterm exists. Option d is incorrect because confirmed diagnosis coding applies only when the impending or threatened condition did occur, and here the condition did not occur.

Correct Answer: Uniform Hospital Discharge Data Set (UHDDS) definitions

The application of the UHDDS definitions has been expanded to all non-outpatient settings, and nursing homes are named among them. The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission. Option a is incorrect because the guidelines describe standardized UHDDS definitions for non-outpatient settings and give no role to definitions that each facility writes for itself. Option b is incorrect because the outpatient guidelines belong to outpatient services, while nursing homes fall within the non-outpatient settings to which the UHDDS definitions were expanded. Option c is incorrect because conventions take precedence over the official guidelines, but they do not supply the principal diagnosis definition, which comes from the UHDDS.

Correct Answer: Reporting the suspected condition as confirmed

Outpatient guidelines prohibit coding diagnoses documented with uncertainty terms such as "suspected." The coder instead reports the condition to the highest degree of certainty, such as symptoms, signs, or abnormal test results. Option a is incorrect because the guideline lists abnormal test results among the findings to code when the provider has not confirmed the diagnosis. Option c is incorrect because symptoms are named in the guidelines as the kind of condition coded to the highest degree of certainty when a diagnosis is uncertain. Option d is incorrect because signs fall under the same instruction, so an outpatient coder may report them instead of the unconfirmed diagnosis.

Correct Answer: Inpatient admissions to facilities subject to a POA collection mandate

The general reporting requirements apply to all claims for inpatient admissions to general acute care hospitals or other facilities subject to a law or regulation mandating collection of present on admission information. Option b is incorrect because the requirements are limited to facilities subject to a law or regulation mandating POA collection, and outpatient surgery is an outpatient setting rather than an inpatient admission. Option c is incorrect because the guidelines treat emergency department conditions as present on admission once an inpatient order occurs; the requirements themselves address inpatient admissions, not these encounters. Option d is incorrect because observation is named only as an outpatient setting whose developing conditions count as present on admission, so it is not a claim type the requirements cover.

Correct Answer: HCPCS Level II

HCPCS Level II is the standardized coding system used primarily to identify products, supplies, and services not included in CPT codes, such as DMEPOS when used outside a physician's office. Option a is incorrect because CPT identifies services and procedures furnished by physicians and other health care professionals, and the scenario describes items that CPT codes do not identify. Option b is incorrect because HCPCS Level I is comprised of CPT, the numeric system maintained by the AMA, and CPT is the system the scenario sets aside. Option d is incorrect because a descriptor is the text defining a code, which belongs to a code set alongside the codes, and it is not a coding system.

Correct Answer: Maintained by CMS, including additions and deletions

CMS maintains HCPCS Level II codes, including decisions on additions, revisions, and deletions. Level I, which is CPT, is maintained by the American Medical Association, so CMS maintenance is not a Level I characteristic. Option a is incorrect because CPT codes are numeric and have five digits, which matches the Level I format; the letter-plus-digits format belongs to Level II. Option c is incorrect because the AMA is the organization that maintains CPT, so this describes Level I accurately and cannot be the odd one out. Option d is incorrect because yearly republication and updating by the AMA is stated for CPT, so this is a genuine Level I trait.

Correct Answer: I and II

Notifiers must give an ABN before a beneficiary receives a covered item with upgrade components that are not medically reasonable and necessary, and a DME upgrade means the upgraded item or component has a different HCPCS code. Statements I and II are accurate. Option b is incorrect because statement III fails: Medicare guidance states ABNs cannot be used to charge beneficiaries for premium quality services described as excess components, even though statement I is accurate. Option c is incorrect because statement IV is wrong, since an item called better or higher quality that does not exceed the HCPCS code description cannot have liability shifted by an ABN. Option d is incorrect because both statements describe uses of the ABN that Medicare guidance prohibits, so this pair contains no accurate statement about upgraded DMEPOS.

Correct Answer: Chapter 17

The general chapter on physician and nonphysician practitioner services refers readers to Chapter 17 for billing and payment for drugs, so drug billing is handled outside the physician chapter itself. Option a is incorrect because the manual assigns preventive services and screening tests to this chapter, so drug billing is described elsewhere. Option b is incorrect because it outlines billing and payment under the laboratory fee schedule, which is a separate service category from drugs. Option d is incorrect because it covers billing and payment for radiology services, not drugs.

Correct Answer: Those valid when the health care is furnished

HIPAA's general requirements in the code set subpart direct a covered entity to use the applicable medical data code sets that are valid at the time the health care is furnished, as the implementation specification provides. Option a is incorrect because the requirement is based on validity on the date care is furnished, so the newest publication does not control if it was not yet valid then. Option c is incorrect because the regulation sets validity by timing in the adopted implementation specification and gives the payer no discretion to choose code sets claim by claim. Option d is incorrect because describes the timing rule for nonmedical data code sets, which are tied to the date the transaction is initiated, not medical data code sets.

Correct Answer: Centers for Medicare & Medicaid Services (CMS)

CMS maintains HCPCS Level II codes, including decisions about additions, revisions and deletions. The authority comes from a delegation by the HHS Secretary under 42 CFR 414.40(a) to establish and maintain uniform national definitions, codes and payment modifiers. Option a is incorrect because the Secretary delegated authority to CMS to establish and maintain national definitions, codes and modifiers, so the maintenance role sits with CMS. Option b is incorrect because these programs are claim payers that rely on standardized coding to process claims, and the guidance gives no code-maintenance decisions to them. Option d is incorrect because it maintains CPT, which makes up HCPCS Level I, and it republishes and updates those codes annually rather than Level II.

Correct Answer: I and II

HIPAA names the National Drug Codes, as maintained and distributed by HHS, for reporting drugs and biologics by retail pharmacies. Durable medical equipment and orthotic and prosthetic devices belong to HCPCS instead. Option b is incorrect because durable medical equipment falls under HCPCS, which covers items other than drugs and biologics, so pairing it with drugs makes this choice fail. Option c is incorrect because orthotic and prosthetic devices are listed among the HCPCS items, not NDC items, and this pairing also leaves out drugs, which NDC does cover. Option d is incorrect because both are equipment categories that the standard assigns to HCPCS, so neither belongs to the retail pharmacy NDC standard.

Correct Answer: Global surgery policy

Under 42 CFR 414.40(b), CMS establishes uniform national ancillary policies needed to implement the fee schedule for physician services. The global surgery policy, covering pre- and post-operative periods and services, is listed first among them. Option a is incorrect because national drug codes are a standard medical data code set maintained by HHS with drug manufacturers, not an ancillary policy CMS sets for the fee schedule. Option b is incorrect because CPT is the Level I coding system maintained by the AMA and republished annually, which makes it a code set rather than a CMS policy. Option d is incorrect because this is a code set for dental services that the American Dental Association maintains, so it is not a CMS fee schedule policy.

Correct Answer: The text defining a code

Under the HIPAA definitions in 45 CFR 162.103, a descriptor means the text defining a code. A code set includes both the codes and the descriptors of those codes. Option a is incorrect because that wording defines a data element in a transaction, which is a different HIPAA term from the text attached to a code. Option b is incorrect because that describes a data condition, which sets the circumstances requiring a covered entity to use a particular data element or segment. Option c is incorrect because that is a code set maintaining organization, an entity creating and maintaining codes, rather than wording that explains a single code.

Correct Answer: I and II

HIPAA names HCPCS, maintained and distributed by HHS, as the standard for all other substances, equipment, supplies, and other items, including durable medical equipment and orthotic and prosthetic devices. Statements I and II are correct. Option b is incorrect because it adds drugs and biologics, which HIPAA assigns to National Drug Codes maintained and distributed by HHS with drug manufacturers, not to HCPCS. Option c is incorrect because dental services belong to the Code on Dental Procedures and Nomenclature from the American Dental Association, and this pairing also leaves out durable medical equipment. Option d is incorrect because both items are covered by other standards: National Drug Codes for drugs and biologics, and the American Dental Association code for dental services.

Correct Answer: Under the drug pricing methodology

Immunizations with hepatitis B, pneumococcal, and influenza vaccines are not included in the fee schedule. Medicare pays them under the drug pricing methodology described in Chapter 17 of the manual. Option a is incorrect because that limit applies to payment for other types of providers, not to these vaccine immunizations, which follow Chapter 17 drug pricing. Option b is incorrect because a charge separate from the ESRD composite rate is recognized for vaccine administration to ESRD patients, so the composite rate does not absorb it. Option c is incorrect because the manual states these immunizations are not included in the fee schedule, so the fee schedule amount is not used for payment.