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

Correct Answer: Code both as if 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 symptom codes are not used as principal diagnosis when a related definitive diagnosis exists, and this guideline treats the either/or diagnoses as if confirmed. Option b is incorrect because the guideline directs coding of both contrasting diagnoses, not just the one documented first, so dropping the second diagnosis misapplies the rule. Option c is incorrect because the guideline already supplies a rule for this situation, so coding does not wait for a determination that cannot be made.

Correct Answer: Established after study to be chiefly responsible for occasioning the admission

The UHDDS defines principal diagnosis as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. The circumstances of inpatient admission govern this selection. Option a is incorrect because resource use does not appear in the UHDDS wording, which relies on the condition established after study and the circumstances of admission. Option b is incorrect because the guidelines direct that the condition occasioning the admission is sequenced first even though treatment may not have been carried out due to unforeseen circumstances. Option d is incorrect because the UHDDS definition gives no weight to when a condition was recorded; it looks to the reason that occasioned the admission.

Correct Answer: Codes for symptoms, signs, and ill-defined conditions

Section II.A states that Chapter 18 codes for symptoms, signs, and ill-defined conditions are not used as principal diagnosis once a related definitive diagnosis has been established for the admission. Option a is incorrect because conditions qualified as probable, suspected or likely at discharge are coded as if established, so inpatient sequencing can treat them as principal. Option b is incorrect because diagnoses documented as either/or are coded as if confirmed and sequenced by the circumstances of admission, so either may come first. Option c is incorrect because when an admission is for treatment of a complication of surgery or other medical care, the complication code is sequenced as the principal diagnosis.

Correct Answer: The postoperative diagnosis

Section IV.N directs coders to code the diagnosis for which surgery was performed. When the postoperative diagnosis is known to differ at confirmation, it is selected because it is the most definitive. Option a is incorrect because principal diagnosis is the inpatient term, and the UHDDS definition does not apply to hospital-based outpatient services, where first-listed diagnosis is used instead. Option c is incorrect because the guideline for ambulatory surgery calls for the diagnosis for which surgery was performed, and says nothing about selecting a symptom as the reported diagnosis. Option d is incorrect because the guideline names the postoperative diagnosis as the one to select when it is known to differ at confirmation, so the preoperative diagnosis is not chosen in that situation.

Correct Answer: Encounter

The guidelines state that the term encounter is used for all settings, including hospital admissions. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated. Option b is incorrect because names the physician or qualified health care practitioner legally accountable for establishing the patient's diagnosis, not the setting-neutral term for the visit or admission. Option c is incorrect because is a level of the Tabular List with 4 or 5 characters, a structural term rather than a term for a visit. Option d is incorrect because refers to the "X" that allows for future expansion at certain codes, which has nothing to do with care settings.

Correct Answer: first-listed

Under Section IV.P, when a general medical examination produces an abnormal finding, the examination code with abnormal finding is assigned as the first-listed diagnosis, and a secondary code is added for the abnormal finding. Option a is incorrect because coexisting conditions are reported with additional codes that describe conditions present at the encounter, so they follow the first-listed diagnosis instead of leading the claim. Option b is incorrect because a postoperative diagnosis applies to ambulatory surgery, where it is selected when it differs from the preoperative diagnosis, not to general medical examinations. Option c is incorrect because additional diagnoses are secondary codes, and the guidelines place the code for the abnormal finding in that role, not the examination code itself.

Correct Answer: The provider's statement that the condition exists

Under the ICD-10-CM guidelines on code assignment and clinical criteria, the provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on the clinical criteria the provider used to establish the diagnosis. Option a is incorrect because the guidelines place the basis for the code in what the provider states, so a coder's own weighing of findings does not decide whether the condition exists. Option b is incorrect because a default code is the one listed next to a main term in the Alphabetic Index and is used when a condition lacks detail, not to confirm existence. Option d is incorrect because the guidelines state that code assignment is not based on the clinical criteria used by the provider to establish the diagnosis.

Correct Answer: Determining when a condition should be coded

The POA guidelines do not guide when a condition should be coded. Code assignment follows Sections I, II, and III of the official guidelines, and the POA indicator is applied afterward to the conditions already coded. Option a is incorrect because the guidelines are described as a supplement to the ICD-10-CM Official Guidelines for Coding and Reporting, so this is a genuine feature. Option c is incorrect because applying the POA indicator to the final set of diagnosis codes assigned under Sections I, II, and III is exactly what the guidelines address. Option d is incorrect because the general reporting requirements cover claims for inpatient admissions to facilities subject to a law or regulation mandating POA collection, so this is a real scope element.

Correct Answer: Having the coder resolve the conflict independently

The POA guidelines state that inconsistent, missing, conflicting or unclear documentation must still be resolved by the provider. The coder queries the provider for clarification and does not settle the conflict independently. Option a is incorrect because the guidelines state that when documentation is unclear at the time of code assignment, it is appropriate to query the provider, so this step is endorsed. Option b is incorrect because determination is based on the applicable POA guideline identified in Appendix I, which makes this a recognized approach rather than an exception. Option d is incorrect because the guidelines name the provider's best clinical judgment as one basis for deciding whether a condition was present on admission, so it fits the guidance.

Correct Answer: Using documentation from any provider involved in the care

The POA guidelines state that medical record documentation from any provider involved in the care and treatment of the patient may be used to support whether a condition was present on admission, so the consultant's note qualifies. Option a is incorrect because the guidelines set no required timeframe for identifying or documenting a condition, so a deadline plays no part in this decision. Option b is incorrect because POA determination rests on medical record documentation or the provider's clinical judgment; the coder's own assumption is not named as a basis for assigning the indicator. Option c is incorrect because the guidelines allow documentation from any provider involved in the patient's care and treatment, so support is not limited to the attending physician.