AAPC-CPC Certified Professional Coder - Set 3 - Part 2

Correct Answer: Modifier -79

Modifier -79 reports an unrelated procedure by the same physician during a postoperative period. A new postoperative period begins when the unrelated procedure is billed, which distinguishes it from the modifiers used for E/M services. Option a is incorrect because it identifies a significant, separately identifiable evaluation and management service on the day of a procedure, which is a different circumstance from a postoperative-period procedure. Option b is incorrect because it is used when physicians agree on transfer of care and one furnishes surgical care only, so it does not describe an unrelated procedure. Option d is incorrect because it reports an unrelated evaluation and management service during a postoperative period, not a procedure, and it does not start a new postoperative period.

Correct Answer: I and II

When physicians agree on a transfer of care during the global period, modifier -54 reports surgical care only and modifier -55 reports postoperative management only. Both bills share the same date of service and procedure code. Option b is incorrect because statement III is false, since both bills carry the same surgical procedure code and the modifier alone distinguishes the services. Option c is incorrect because statement IV is false; Medicare guidance has both bills show the same date of service, so only the modifier separates them. Option d is incorrect because it pairs two false statements, because different codes and different dates are not how split-care bills are distinguished; the modifiers do that.

Correct Answer: Penalties under the Social Security Act

Medicare's policies on billing patients above the allowed amount apply to assistant-at-surgery services. Physicians who knowingly and willfully violate this prohibition may face penalties under section 1842(j)(2) of the Social Security Act, varying with frequency and seriousness. Option a is incorrect because the 16 percent figure is the normal payment level for assistant-at-surgery services, not a sanction for billing a beneficiary improperly. Option b is incorrect because modifier -50 identifies bilateral surgeries on both sides of the body, so it does not address excess billing of a beneficiary. Option c is incorrect because nonfacility rates concern setting-based payment for rehabilitative therapy and CORF services, and have no link to billing a beneficiary.

Correct Answer: Separate values for the global service, professional component, and technical component

For diagnostic procedure codes and other codes describing services with both professional and technical components, Medicare provides relative values for the global service, the professional component, and the technical component. CMS determines which HCPCS codes fall into this category. Option b is incorrect because the fee schedule gives relative values for each of the three billing forms, so a global-only value would leave the component billing options unpriced. Option c is incorrect because A/B MACs (B) set local values only for national codes lacking national relative values, while CMS provides values for these dual-component services. Option d is incorrect because individual consideration applies to surgeries billed with the -22 or -52 modifier when documentation is included, not to component-based diagnostic services.

Correct Answer: The appropriate inpatient POS code

Medicare treats a registered hospital inpatient or outpatient as an exception to the general rule. The POS code is the appropriate inpatient code, at a minimum POS 21, regardless of where the face-to-face service occurs. Option a is incorrect because the office code reflects the actual setting for a typical face-to-face encounter, but the hospital inpatient exception overrides that general rule even when the patient is seen in the office. Option b is incorrect because the address and ZIP in the service location item normally match the code, yet the inpatient exception produces a code that differs from the practice location. Option d is incorrect because that code is shown when a physician bills for a lab test furnished by another physician who maintains an office lab, not for inpatients.

Correct Answer: Section II

Section II of the guidelines holds the rules for selection of principal diagnosis for non-outpatient settings. Section III covers additional diagnoses, and all sections must be reviewed to understand the rules needed to code properly. Option a is incorrect because deals with reporting additional diagnoses in non-outpatient settings, which follows after the principal diagnosis has already been selected. Option b is incorrect because is reserved for outpatient coding and reporting, so it falls outside the non-outpatient scope named in the question. Option c is incorrect because covers the structure and conventions of the classification, general guidelines and chapter-specific guidelines, not principal diagnosis selection for non-outpatient settings.

Correct Answer: the Health Insurance Portability and Accountability Act

The ICD-10-CM Official Guidelines state that adherence to them when assigning 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 Tabular List instructions are part of the classification and take precedence over the guidelines, but they are not the legal source of the requirement. Option c is incorrect because the WHO publishes the ICD-10, the statistical classification on which ICD-10-CM is based, but it does not impose the guideline requirement. Option d is incorrect because the four Cooperating Parties approve the guidelines, which makes them official, yet the legal requirement to follow them comes from a different source.

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 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 c 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 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: I, II, and IV

The Alphabetic Index does not always provide the full code, and the full code including any 7th character is selected in the Tabular List. A three-character code is used only if it is not further subdivided. Notations apply in both parts. Option a is incorrect because it leaves out statement IV, which is also accurate: the guidelines direct that a three-character code be used only when the category is not further subdivided. Option c is incorrect because it accepts statement III, but the guidelines tell the coder to read and be guided by notations in both the Alphabetic Index and the Tabular List. Option d is incorrect because it relies on statement III, which is wrong, and drops statement I, even though the Alphabetic Index does not always give the complete code.

Correct Answer: Unspecified

The ICD-10-CM guidelines on abbreviations state that NOS, "not otherwise specified," is the equivalent of unspecified. This holds for the abbreviation in both the Alphabetic Index and the Tabular List. Option a is incorrect because the guidelines give this meaning to the words "with" and "in," which signal a presumed causal relationship, not to NOS. Option b is incorrect because this is what the abbreviation NEC represents; NEC directs the coder to the "other specified" code when no specific code exists. Option c is incorrect because this is the full wording of NEC, a different abbreviation from NOS, which stands for "not otherwise specified."

Correct Answer: Default code

A code listed next to a main term in the Alphabetic Index is a default code. It represents the condition most commonly associated with the main term, or the unspecified code, and is assigned when documentation adds no detail. Option a is incorrect because it is an instruction that two codes may be required to describe a condition, and it gives no sequencing direction. Option b is incorrect because NEC marks an Alphabetic Index line that points to an "other specified" code for a condition with no specific code. Option d is incorrect because inclusion terms are lists of conditions placed under a code in the Tabular List, not a code printed beside a main term in the Index.

Correct Answer: Following the cross-reference is not necessary

A "see also" instruction points to another main term that may offer additional Alphabetic Index entries. The guidelines state it is not necessary to follow it when the original main term provides the necessary code. Option a is incorrect because a "see also" note only points to additional Index entries that may be useful; it does not direct the coder to report codes from both terms. Option b is incorrect because a "see" instruction, not "see also", makes it necessary to go to the referenced main term to locate the correct code. Option c is incorrect because the guidelines describe "see also" as an Alphabetic Index instruction and say nothing about replacing the Index with the Tabular List.

Correct Answer: I and III

The ICD-10-CM guidelines base code assignment on the provider's diagnostic statement that the condition exists, and not on clinical criteria. When medical record documentation conflicts, the coder queries the provider. Statements I and III are correct. Option b is incorrect because statement II is wrong, since the guidelines state that code assignment is not based on the clinical criteria the provider used to establish the diagnosis. Option c is incorrect because both statements fail: coders do not verify clinical criteria, and conflicting documentation is resolved by asking the provider rather than by the coder choosing a diagnosis. Option d is incorrect because statement III is sound, but IV contradicts the instruction to query the provider; the coder does not decide which conflicting diagnosis seems more likely.

Correct Answer: The reason for the surgery

The outpatient guidelines direct that the reason for the surgery is coded as the first reported diagnosis, which is the reason for the encounter. Codes for the complications that led to observation follow as secondary diagnoses. Option a is incorrect because the UHDDS definition of principal diagnosis does not apply to hospital-based outpatient services, where the term first-listed diagnosis is used instead. Option b is incorrect because symptom codes are acceptable only when a related diagnosis has not been established, and the guidelines here direct the reason for the surgery to come first. Option d is incorrect because the guidelines list complications as secondary diagnoses that follow the first reported diagnosis, so a complication is not placed in the first position.

Correct Answer: "Other" code

Alphabetic Index entries with NEC in the line designate "other" codes in the Tabular List. They stand for specific disease entities for which no specific code exists, so the term is included within an "other" code. Option a is incorrect because unspecified codes are for records whose information is insufficient for a more specific code, but here the provider documented a specific, identifiable condition. Option b is incorrect because a default code is the one listed beside a main term, representing the most common condition or the unspecified code, not an NEC entry. Option c is incorrect because this is an instructional notation saying two codes may be needed to describe a condition, and it does not designate a code type.

Correct Answer: Home health agency

The UHDDS definitions extend to all non-outpatient settings, including home health agencies. The uncertain diagnosis guideline, however, applies only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals, which excludes home health agencies. Option a is incorrect because the guideline note expressly lists long-term care hospitals among the inpatient admissions where a qualified diagnosis at discharge is coded as established. Option b is incorrect because it is named in the UHDDS list and also in the note limiting the uncertain diagnosis guideline, so it is covered by both. Option d is incorrect because psychiatric hospitals sit in both groups, so a discharge diagnosis qualified as probable or suspected there is still coded as if established.

Correct Answer: Causal condition sequenced as principal or first-listed

When a causal condition is known, the "Code, if applicable, any causal condition first" note directs that the causal condition be sequenced as the principal or first-listed diagnosis. The noted code may be principal only when the cause is unknown or not applicable. Option b is incorrect because this reverses the instruction, since the note allows the code to be principal only when the causal condition is unknown or not applicable. Option c is incorrect because the guidelines direct that a known causal condition be sequenced first, so leaving it off contradicts the note. Option d is incorrect because a combination code is identified through Alphabetic Index subterms and Tabular List notes, not through a causal condition note, which concerns sequencing.

Correct Answer: Sequela (late effect)

A sequela is the residual effect, or condition produced, after the acute phase of an illness or injury has terminated. The guidelines set no time limit, and infertility due to tubal occlusion from old tuberculosis is a listed example. Option a is incorrect because that guideline covers conditions described at discharge as impending or threatened, and here the infertility has already occurred as a residual effect. Option c is incorrect because a borderline diagnosis is one the provider documents as borderline, which is coded as confirmed unless the classification gives a specific entry; no such wording appears here. Option d is incorrect because a combination code is a single code classifying two diagnoses or a diagnosis with a manifestation or complication, not a residual condition after an acute phase ended.

Correct Answer: As a confirmed diagnosis

The Borderline Diagnosis guideline directs that a borderline diagnosis documented at discharge is coded as confirmed, unless the classification provides a specific entry, such as borderline diabetes, which is then coded as indexed. Option a is incorrect because borderline conditions are not uncertain diagnoses, according to the guideline, so the rules for uncertain diagnoses do not apply to them. Option b is incorrect because unspecified codes fit cases where clinical information is too limited for a more specific code, not borderline diagnoses, which are coded as confirmed. Option c is incorrect because sign and symptom codes are reported when no definitive diagnosis has been established, which is a different situation from a documented borderline diagnosis.

Correct Answer: As if it existed or was established

The uncertain diagnosis guideline says that a discharge diagnosis qualified by terms such as "consistent with," "probable" or "suspected" is coded as if it existed or was established, for inpatient admissions to the listed hospitals. Option a is incorrect because history codes cover resolved or family conditions that affect current care, which is a different situation from a diagnosis still qualified as uncertain at discharge. Option c is incorrect because abnormal findings are a separate topic, reported only when the provider indicates clinical significance; a qualified diagnosis at discharge is handled by the uncertain diagnosis rule. Option d is incorrect because the guidelines direct coding the uncertain condition itself as established, not reducing it to a symptom while waiting for confirmation of the diagnosis.