AAPC-CPMA Certified Professional Medical Auditor - Set 4 - Part 1

Correct Answer: I and II

Under the etiology/manifestation convention, the etiology code carries a "use additional code" note and the manifestation code carries a "code first" note. Together these notes require sequencing of etiology followed by manifestation. Option b is incorrect because statement III is false, since "in diseases classified elsewhere" codes are never permitted as first listed or principal diagnosis codes. Option c is incorrect because statement IV reverses the Alphabetic Index structure, which lists the etiology code first and puts the manifestation code in brackets afterward. Option d is incorrect because both statements are wrong: manifestation codes must follow the underlying condition, and the Index puts the etiology code ahead of the bracketed manifestation.

Correct Answer: Precedence over the classification's own instructions

The conventions and instructions of the classification take precedence over the guidelines, so the guidelines do not override them. The other three statements are accurate: HIPAA requires adherence, the Cooperating Parties approve them, and they serve as a companion document. Option a is incorrect because the guidelines state that following them when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act. Option b is incorrect because the guidelines describe themselves as a companion document to the official version of the ICD-10-CM published on the NCHS website. Option d is incorrect because the AHA, AHIMA, CMS and NCHS together make up the Cooperating Parties, and the guidelines are stated to be approved by all four.

Correct Answer: Placeholder X fills the empty characters

When a code requiring a 7th character is not 6 characters, a placeholder X must fill the empty characters. The 7th character must always stay in the 7th position of the data field, or the code is invalid. Option a is incorrect because unspecified codes are used when medical record information is insufficient for a more specific code, which does not address missing characters in a code. Option b is incorrect because the 7th character must always be the 7th character in the data field, so its position cannot shift to fill the gap. Option c is incorrect because reporting purposes allow only codes, not categories or subcategories, and any applicable 7th character is still required.

Correct Answer: It is equivalent to a code and is reportable

A three-character category that has no further subdivision is equivalent to a code. Because reporting permits only codes, not categories or subcategories, this undivided category can be reported as it stands. Option a is incorrect because the placeholder X fills empty characters at certain codes for future expansion or a 7th character, which is unrelated to an undivided category. Option b is incorrect because subcategories are 4 or 5 characters, so a three-character entry cannot be one; categories are always 3 characters. Option d is incorrect because a 7th character is required only for codes that have an applicable 7th character, and nothing here indicates one applies.

Correct Answer: "Code also" note

A "code also" note tells the coder that two codes may be required to fully describe a condition. It gives no sequencing direction, so the order depends on the circumstances of the encounter. Option a is incorrect because it directs the coder to another main term in the Alphabetic Index that may offer additional entries, and it does not concern reporting two codes. Option b is incorrect because it is a sequencing rule that sets the order of codes, so it does give direction on which code is listed first. Option c is incorrect because it works as a sequencing rule in the classification, so sequencing direction is supplied, unlike the note that leaves order to the encounter.

Correct Answer: Begin the search in the Alphabetic Index

The outpatient guidelines call beginning the search through the Alphabetic Index the most critical rule. Starting initially in the Tabular List is warned against because it leads to coding errors. Option a is incorrect because guidelines for inconclusive diagnoses such as probable or suspected were developed for inpatient reporting and do not apply to outpatients; they also say nothing about where to search. Option b is incorrect because diagnoses often are not established at the first encounter and may take two or more visits, which does not change where the code search starts. Option d 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 guide the search.

Correct Answer: Reporting codes at their highest number of characters available

Diagnosis codes are to be reported at their highest number of characters available. A three-character code is used only when it is not further subdivided, and a code lacking required characters is invalid. Option a is incorrect because a "code also" note says two codes may be required and gives no sequencing direction, so it has no bearing on code length. Option c is incorrect because a default code is the one listed next to a main term in the Alphabetic Index and is used when no further detail is documented. Option d is incorrect because this guideline presumes a causal relationship between two conditions linked in the classification; it concerns linkage of conditions, not how many characters a code carries.

Correct Answer: The level of certainty known for that encounter

The ICD-10-CM guidelines on use of sign/symptom/unspecified codes state that each healthcare encounter should be coded to the level of certainty known for that encounter, so sign, symptom or unspecified codes can be the best choice. Option a is incorrect because a starting impression does not set the standard; the entire record is reviewed to determine the reason for the encounter and the conditions treated. Option b is incorrect because the guidelines call for coding what is known at that encounter, and they reject medically unnecessary testing performed just to reach a more specific code. Option c is incorrect because specificity is limited to what the record documentation and clinical knowledge of the patient support; a code the record does not support is inappropriate.

Correct Answer: The bilateral code

The laterality guideline directs assignment of the bilateral code for the first-side encounter, because the condition still exists on both sides. The unilateral code applies only at the later encounter, once the treated side no longer has the condition. Option b is incorrect because unspecified-side codes are reserved for rare cases where the affected side cannot be determined and clarification is impossible, which is not the situation here. Option c is incorrect because separate codes for each side apply only when no bilateral code is provided, and here a bilateral code exists to use. Option d is incorrect because the condition still exists on both sides at that first encounter, so a code for only the treated side would understate the patient's condition.

Correct Answer: Assign codes for the documented manifestations

ICD-10-CM guidelines for syndromes direct the coder to follow Alphabetic Index guidance. When the Index offers none, codes are assigned for the documented manifestations of the syndrome. Option a is incorrect because a sequela is a residual effect after the acute phase of an illness or injury has ended, which is a different concept from a syndrome. Option b is incorrect because a combination code classifies two diagnoses or a diagnosis with a manifestation or complication, and it is found through Index subterms or Tabular notes, not by default. Option d is incorrect because the guidelines do not call for a query here; they direct the coder to the documented manifestations when the Alphabetic Index is silent.

Correct Answer: Code the existing underlying condition(s)

Under the Impending or Threatened Condition guideline, when the condition did not occur and the Alphabetic Index lists no subterm, the coder codes the existing underlying condition(s) and not the condition described as threatened. Option a is incorrect because a query is encouraged for unclear borderline documentation, but the guideline for threatened conditions supplies its own steps and names no query here. Option b is incorrect because confirmed-diagnosis coding is directed for a threatened condition that did occur, and the documentation here states that this condition did not occur. Option c is incorrect because the guideline for impending or threatened conditions directs the coder to the underlying condition when no subterm is listed, and does not mention unspecified codes for this situation.

Correct Answer: Acute phase of the original injury

A sequela is the residual effect after the acute phase has terminated. The acute phase of the illness or injury is not a sequela, and its code is never used with a code for the late effect. Option b is incorrect because the guidelines list it as a residual effect, a scar left after the acute burn phase has ended. Option c is incorrect because the guidelines name it directly, showing that a residual condition can follow an old illness long after the acute phase. Option d is incorrect because it appears among the guideline examples, since the septal deformity is the condition produced after the fracture's acute phase.

Correct Answer: Pregnant women

The Documentation Guidelines state that records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area, differing from the typical adult population. Option a is incorrect because the guidelines name infants, children, adolescents and pregnant women as the groups with modified recording, and elderly adults are not among them. Option b is incorrect because patient status is not a group the guidelines single out; they reflect the typical adult population and name only specific patient groups as varying. Option d is incorrect because this describes a place of service listed among the E/M descriptors, not a patient group whose history and examination recording varies.

Correct Answer: It required clinical evaluation and monitoring

Other diagnoses are additional clinically significant conditions that affect patient care by requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, or increased nursing care and monitoring. Lab monitoring and consultation meet this definition. Option b is incorrect because symptom and sign codes concern ill-defined conditions and limit principal diagnosis selection; they are not the criterion that makes a coexisting disease reportable as additional. Option c is incorrect because principal diagnosis is the condition established after study to be chiefly responsible for the admission, which here is the pneumonia, not a coexisting condition. Option d is incorrect because conditions relating to an earlier episode with no bearing on the current stay are excluded, and here the kidney disease directly affected current care.

Correct Answer: The complication

Under the guideline for complications of surgery and other medical care, when the admission is for treatment of a complication, the complication code is sequenced as the principal diagnosis. The original surgical condition does not take that position. Option a is incorrect because an unrelated condition becomes principal only when it is the documented reason for the inpatient admission after outpatient surgery, which is a different situation from treating a complication. Option c is incorrect because the guideline gives the original surgical condition no priority when the admission is for treating a complication; that condition would only lead sequencing in the outpatient surgery scenario without a documented complication. Option d is incorrect because free choice of sequencing applies to contrasting or comparative diagnoses documented as either/or when no further determination can be made, not to complications of care.

Correct Answer: The condition for which the service is performed

The rehabilitation guideline states that when the purpose for the admission or encounter is rehabilitation, the condition for which the service is being performed is sequenced first, such as hemiplegia following a cerebral infarction. Option b is incorrect because a complication is sequenced first only when the admission is for treatment of a complication from surgery or other medical care, not for rehabilitation. Option c is incorrect because the rehabilitation guideline directs sequencing to the underlying condition being treated, and symptoms are not named as the first-listed diagnosis for these admissions. Option d is incorrect because this rule applies to an inpatient admission following outpatient surgery when no complication or other condition is documented, which is a different circumstance from rehabilitation.

Correct Answer: Inpatient admission to a short-term acute care hospital

The uncertain diagnosis guideline applies only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals. Qualified diagnoses at discharge are coded as if they existed or were established. Option a is incorrect because coding guidelines for inconclusive diagnoses were developed for inpatient reporting and do not apply to outpatients, including hospital-based outpatient services. Option b is incorrect because hospital-based outpatient services and provider-based office visits are each excluded from the uncertain diagnosis guideline, so neither treats such terms as established. Option c is incorrect because office visits fall under the outpatient guidelines in Section IV, which state that the inconclusive diagnosis guidelines do not apply to outpatients.

Correct Answer: do not code related signs and symptoms

Under the outpatient guideline for patients receiving diagnostic services only, a confirmed or definitive diagnosis documented in the physician's interpretation is coded, and related signs and symptoms are not coded as additional diagnoses. Option b is incorrect because uncertain terms such as probable or suspected are not coded in outpatient reporting; the condition is coded to the highest degree of certainty instead. Option c is incorrect because a routine-testing Z code applies when no sign, symptom or diagnosis exists, and it is added alongside a non-routine test reason, not substituted for it. Option d is incorrect because the guideline for interpreted diagnostic tests tells the coder not to add related signs and symptoms as additional diagnoses once a definitive diagnosis is documented.

Correct Answer: Coded to the highest degree of certainty for that encounter

Outpatient guidelines prohibit coding diagnoses documented as probable, suspected, questionable or rule out. The coder instead reports the condition to the highest degree of certainty for that encounter, such as symptoms, signs or abnormal test results. Option a is incorrect because that is the inpatient rule for uncertain diagnoses at discharge in short-term, acute, long-term care and psychiatric hospitals, and outpatient guidelines state they differ from it. Option c is incorrect because the UHDDS principal diagnosis definition does not apply to hospital-based outpatient services and provider-based office visits, which use the term first-listed diagnosis instead. Option d is incorrect because history codes are secondary codes for conditions previously treated that no longer exist but still influence current care; a suspected condition is not that.

Correct Answer: Report it as many times as treatment is received

Under the outpatient guidelines for chronic diseases, a chronic disease treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition. Option b is incorrect because history codes are for conditions that no longer exist or that affect current care as a past or family factor, not a condition under active treatment. Option c is incorrect because the outpatient guideline lets a chronic disease treated on an ongoing basis be reported at each encounter, so a single first-visit limit does not exist. Option d is incorrect because a chronic condition may also be sequenced as an additional diagnosis, so reporting is not restricted to the first-listed position.