AAPC-CPC Certified Professional Coder - Set 2 - Part 2

Correct Answer: It is an intent-based, criminal statute

The Federal anti-kickback statute is an intent-based, criminal statute that prohibits remuneration, monetary or in-kind, in exchange for referrals of Federal health care program business, including gifts rewarding past or future referrals. Option a is incorrect because the list of designated health services belongs to the physician self-referral provisions, which define services subject to referral limits, not to the anti-kickback statute. Option c is incorrect because OIG guidance states its overviews do not address State fraud and abuse laws; the anti-kickback statute is a Federal authority. Option d is incorrect because repayment of overpayments is one possible consequence of violating these laws, alongside criminal penalties, fines and exclusion, and does not define the statute.

Correct Answer: Documenting the reason for each patient encounter

Recording the reason for each patient encounter is an internal documentation guideline that supports accurate billing. It is a compliance safeguard, not a false statement or improper payment scheme, so it is not a fraud example. Option a is incorrect because the manual counts bribes, kickbacks, or rebates paid or received to induce referrals as fraud, so this is a listed example. Option b is incorrect because changing claims forms or receipts to raise the payment amount appears by name in the manual's list of fraud examples. Option d is incorrect because the Medicare manual lists this under billing for services not furnished, which makes it a named example of fraud.

Correct Answer: Proof of specific intent to defraud

The False Claims Act defines knowing to include actual knowledge, deliberate ignorance, or reckless disregard, and states that no proof of specific intent to defraud is required. Liability therefore cannot be avoided by ignoring inaccuracies. Option b is incorrect because reckless disregard of truth or falsity is the third defined form of knowing, so it can satisfy the standard. Option c is incorrect because acting in deliberate ignorance of the truth or falsity of information is one of the three defined forms of knowing. Option d is incorrect because actual knowledge is the first listed way a person acts knowingly, so a claim can rest on it directly.

Correct Answer: Reducing the amount due and owing

Through the CMS Voluntary Self-Referral Disclosure Protocol, providers and suppliers self-disclose actual or potential PSL violations, and CMS has the authority to reduce the amount due and owing for those violations. Option a is incorrect because the PSL is a strict liability statute, and nothing in the SRDP changes that standard of liability for a disclosed arrangement. Option c is incorrect because the PSL and the Federal anti-kickback statute are separate laws, so an arrangement that passes the PSL still needs its own anti-kickback review. Option d is incorrect because the SRDP lets providers and suppliers self-disclose potential violations as well as actual ones, so it is not confined to confirmed violations.

Correct Answer: Double billing resulting in duplicate payment

OIG guidance lists double billing resulting in duplicate payment among the coding and billing risk areas most frequently investigated and audited. It occurs when the same item or service is billed more than once. Option a is incorrect because a random sample of claims is an audit method the guidance recommends for finding problems, so it is a safeguard rather than a risk area. Option b is incorrect because generating a repayment with explanation is described as an appropriate response once a problem is identified, which makes it a corrective step instead of a vulnerability. Option d is incorrect because clear written standards and procedures shared with all employees are called important to program effectiveness; they help reduce risk and are not themselves a billing risk.

Correct Answer: Subcontractor handling protected health information for the associate

The HIPAA definition of business associate includes a subcontractor that creates, receives, maintains, or transmits protected health information on behalf of the business associate. The other roles listed fall under the stated exclusions. Option a is incorrect because the definition carves out a government agency that determines eligibility for or enrollment in a government health plan administered by another agency, where authorized by law. Option c is incorrect because a plan sponsor is excluded when the group health plan's disclosures meet the requirements of § 164.504(f), so that role is not a business associate. Option d is incorrect because the definition expressly excludes a health care provider with respect to disclosures by a covered entity concerning the treatment of the individual.

Correct Answer: Data content

Data content means all the data elements and code sets inherent to a transaction and not related to its format. Data elements tied to format are expressly excluded from data content. Option a is incorrect because it is a rule describing when a covered entity must use a particular data element or segment, not a portion of the transaction. Option b is incorrect because it names the very portion the analyst set aside, the data elements that provide or control enveloping or hierarchical structure, so it excludes code sets. Option d is incorrect because it denotes a semantically meaningful unit of information exchanged between two parties, which is a unit of exchange rather than the code-set-bearing portion of a transaction.

Correct Answer: A reasonable cost-based fee

For research disclosures under the Privacy Rule, the only remuneration the covered entity or business associate may receive is a reasonable cost-based fee to cover the cost to prepare and transmit the protected health information. Option a is incorrect because grant funding is not a cost-based fee; the rule limits remuneration to covering preparation and transmission costs for the disclosure. Option c is incorrect because the research provision permits only a cost-based fee covering preparation and transmission, so pricing the information at what it could fetch exceeds that limit. Option d is incorrect because a royalty ties payment to the research outcome rather than to the cost of preparing and transmitting the information, which the provision does not allow.

Correct Answer: Review the entire record

The guidelines state that the entire record should be reviewed to determine the specific reason for the encounter and the conditions treated, because accurate coding cannot be achieved without consistent, complete documentation. Option a is incorrect because the guidelines describe a joint effort between provider and coder for complete documentation, and deferring to a later visit is not part of that process. Option b is incorrect because Section II covers principal diagnosis selection in non-outpatient settings, so it does not resolve unclear documentation for an outpatient encounter. Option d is incorrect because the guidelines direct review of the whole record to find the reason for the encounter and conditions treated, not reliance on one entry.

Correct Answer: 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 conventions and instructions within the ICD-10-CM itself, rather than replacing them. Option a is incorrect because the guidelines never name payer policies as a source of precedence; they rely on the classification itself and the approval of the Cooperating Parties. Option b is incorrect because the guidelines give provider documentation a role in supporting accurate coding, but it is not described as overriding the guidelines when the two differ. Option c is incorrect because Section IV is one part of the guidelines, covering outpatient coding and reporting, so it cannot outrank the classification's own instructions.

Correct Answer: "Code also" note

A "code also" note instructs that two codes may be required to fully describe a condition. It does not provide sequencing direction, so the order depends on the circumstances of the encounter. Option a is incorrect because it is a sequencing rule, used with etiology/manifestation combinations and certain other codes, so it does direct which code is reported first. Option c is incorrect because it appears under a three-character code title to further define or give examples of the category content, and it does not call for a second code. Option d is incorrect because the guidelines treat it as a sequencing rule alongside "Code first", so it does give direction on order, unlike the note described.

Correct Answer: Go to the referenced term to locate the code

A "see" instruction following a main term in the Alphabetic Index indicates that another term should be referenced. The coder must go to the main term named in the note, because that is where the correct code is located. Option a is incorrect because that describes the optional "see also" instruction, which need not be followed when the original main term already provides the necessary code. Option b is incorrect because an Excludes1 note is a Tabular List convention meaning "NOT CODED HERE!" for two codes that cannot occur together; it is unrelated to Index cross-references. Option c is incorrect because "other specified" codes are tied to NEC entries, which mark conditions with no specific code; a "see" instruction is a redirection to another term, not that.

Correct Answer: Report the documented symptom code

Codes that describe symptoms and signs are acceptable for reporting when the provider has not established a definitive diagnosis. Each encounter is coded to the level of certainty known for that encounter. Option b is incorrect because a diagnosis the provider has not established is not what the encounter supports; the guidelines tie reporting to the level of certainty known for that encounter. Option c is incorrect because the guidelines call for coding each encounter to its own known certainty, so reporting does not wait for a later confirmation. Option d is incorrect because specific diagnosis codes belong to conditions supported by the medical record documentation, and here the provider has documented only the symptom.

Correct Answer: Assign only the combination code

A combination code classifies a diagnosis with an associated complication in one code. When it fully identifies all documented elements, only that code is assigned, and multiple coding should not be used. Option a is incorrect because adding separate codes for elements the combination code already identifies is multiple coding, which the guidelines discourage when one code clearly covers all documented elements. Option b is incorrect because a default code applies when a condition is documented without additional information, but this diagnosis carries documented detail that the combination code captures. Option c is incorrect because symptom codes are acceptable only when a related definitive diagnosis has not been established, and here the provider has documented a diagnosis.

Correct Answer: Query the provider

Code assignment is based on the provider's diagnostic statement that the condition exists. When medical record documentation conflicts, the guideline for code assignment and clinical criteria directs the coder to query the provider. Option b is incorrect because code assignment rests on the provider's diagnostic statement, not on clinical criteria the provider used to establish the diagnosis, so the coder does not judge the criteria. Option c is incorrect because a default code applies when a condition is documented without added detail such as acute or chronic, not when entries in the record conflict. Option d is incorrect because a three-character code is used only when it is not further subdivided, which concerns level of detail and does not settle conflicting documentation.

Correct Answer: Coded as if it existed or was established

Section III.C, Uncertain Diagnosis, states that a diagnosis documented at discharge with terms such as "probable," "suspected," or "likely" is coded as if it existed or was established, based on the workup and treatment. Option a is incorrect because a query is the suggested step for abnormal findings of unclear significance, while the uncertain diagnosis guideline directs the coder to code the condition directly. Option b is incorrect because hospital policy is the condition for reporting resolved conditions and status-post procedures from previous admissions, which is a different guideline from uncertain diagnosis. Option c is incorrect because history codes are secondary codes for historical or family conditions affecting current care, and they do not describe a diagnosis still qualified by uncertainty at discharge.

Correct Answer: The acute (subacute) code

When one condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, both are coded and the acute (subacute) code is sequenced first. Option b is incorrect because a default code is the entry listed next to a main term, used when no acute or chronic detail is documented, so it does not set this order. Option c is incorrect because a combination code is a single code classifying two diagnoses or a diagnosis with a manifestation or complication; this rule does not involve one. Option d is incorrect because the guideline places the chronic code after the acute code when both are reported, so it is not listed first.

Correct Answer: Confirmed

The outpatient uncertain diagnosis guideline lists terms such as probable, suspected, rule out and working diagnosis as indicating uncertainty. A confirmed diagnosis is established by the provider and may be coded; it is not an uncertainty term. Option a is incorrect because it is one of the terms the outpatient guideline lists as indicating uncertainty, so a diagnosis documented this way is not coded. Option b is incorrect because the outpatient uncertain diagnosis guideline names it among the inconclusive terms, which means the condition is not reported as a diagnosis. Option c is incorrect because the guideline names it directly alongside suspected and questionable, so coders do not report a condition documented with it.

Correct Answer: UHDDS definition of principal diagnosis

The outpatient guidelines state that the UHDDS definition of principal diagnosis does not apply to hospital-based outpatient services and provider-based office visits. The term first-listed diagnosis is used in lieu of principal diagnosis. Option a is incorrect because the guidelines call beginning in the Alphabetic Index the most critical rule, so it does apply to outpatient code selection. Option c is incorrect because the outpatient guidelines direct that Section I conventions, general guidelines and chapter-specific guidelines also be applied to outpatient services and office visits. Option d is incorrect because these take precedence over the outpatient guidelines when the first-listed diagnosis is determined, so they remain in force for outpatient encounters.

Correct Answer: Do not report it separately with the related procedure

CMS interprets the "separate procedure" designation to prohibit separate reporting when the procedure is performed with another procedure in an anatomically related region, often through the same skin incision, orifice, or surgical approach. Option a is incorrect because the guidance bars separate reporting of the designated code with the related procedure; it does not tell the coder to drop the related procedure. Option b is incorrect because the designation bars separate reporting when the procedure is performed with another procedure in an anatomically related region, and a shared encounter does not change that. Option d is incorrect because modifier 59 is appended to indicate a separately reportable service, such as an unrelated area or separate encounter, and the same incision in a related region does not qualify.