AAPC-CRC Certified Risk Adjustment Coder - Set 2 - Part 1

Correct Answer: Section IV

The guidelines are organized into sections, and Section IV is the section for outpatient coding and reporting. A physician office visit is an outpatient encounter, so Section IV is the one the coder consults. Option a is incorrect because it addresses selection of principal diagnosis, and it is written for non-outpatient settings rather than for an office visit. Option c is incorrect because its subject is reporting additional diagnoses, again directed to non-outpatient settings, so an outpatient office encounter falls outside its scope. Option d is incorrect because it covers the structure and conventions of the classification, general guidelines, and chapter-specific guidelines, not rules written specifically for outpatient coding and reporting.

Correct Answer: The Cooperating Parties

The four organizations making up the Cooperating Parties (AHA, AHIMA, CMS and NCHS) approve the guidelines, and only this set of guidelines approved by the Cooperating Parties is official. Option b is incorrect because the WHO publishes the ICD-10, the statistical classification on which ICD-10-CM is based, but it is not named as the approving body for these guidelines. Option c is incorrect because HIPAA is a law that makes adherence to the guidelines required and adopts the diagnosis codes; it does not approve the guidelines. Option d is incorrect because DHHS is the federal department housing CMS and NCHS; approval is given by the four Cooperating Parties, not by the department as a whole.

Correct Answer: Morbidity classification

The ICD-10-CM Official Guidelines describe ICD-10-CM as a morbidity classification published by the United States for classifying diagnoses and reason for visits in all health care settings. Option a is incorrect because payment is not the stated function; the guidelines identify ICD-10-CM purely as a way to classify diagnoses and visit reasons. Option b is incorrect because procedures are not the focus here, since the guidelines place ICD-10-CM as the system for classifying diagnoses and reason for visits. Option c is incorrect because mortality classification is not how the guidelines describe ICD-10-CM; they call it a morbidity classification covering diagnoses and reasons for visits.

Correct Answer: 3 characters

The ICD-10-CM format and structure convention states that all categories are 3 characters. A three-character category with no further subdivision is equivalent to a code, while subcategories and other codes are longer. Option a is incorrect because 5 characters is the longest length given for a subcategory, so it describes a later level of subdivision, not categories. Option c is incorrect because 7 characters is the longest a code can be, and codes with a 7th character are still called codes, not categories. Option d is incorrect because a 4-character entry is a subcategory or a code, which follows a category in the structure rather than being the category itself.

Correct Answer: It has no further subdivision

The guidelines on level of detail state that a three-character code is to be used only if it is not further subdivided. A category with subdivisions is invalid when reported at three characters. Option b is incorrect because a category can lack a 7th character yet still be subdivided into fourth, fifth or sixth characters, so that fact alone does not make three characters valid. Option c is incorrect because unspecified documentation points to a default or unspecified code at the full number of characters; it does not permit stopping at the category level. Option d is incorrect because a missing dash in the Alphabetic Index does not settle the matter, since the Tabular List must still be checked to verify the required characters.

Correct Answer: The condition produced after the acute phase has terminated

The guidelines define a sequela as the residual effect, or condition produced, after the acute phase of an illness or injury has terminated. Examples include scar formation after a burn and a deviated septum due to a nasal fracture. Option a is incorrect because that situation calls for coding both conditions with the acute code first when separate subentries exist, and it says nothing about residual effects after an acute phase. Option b is incorrect because that describes a combination code, which classifies two diagnoses or a diagnosis with a secondary process or complication, not a residual effect of a finished illness. Option d is incorrect because the guidelines treat a threatened or impending condition separately, directing the coder to confirm whether it occurred or to check the Alphabetic Index subentries.

Correct Answer: Alphabetic Index

The most critical rule is to begin the search for the correct code assignment through the Alphabetic Index. The code is then verified in the Tabular List, and beginning there initially leads to coding errors. Option a is incorrect because the conventions explain abbreviations, punctuation and symbols used in the Tabular List, but they do not give the starting point for locating a code. Option c is incorrect because these guidelines correspond to the classification chapters and add instructions for particular conditions; they do not set where the search for a code starts. Option d is incorrect because the guidelines warn against beginning there, because starting in that part of the classification leads to coding errors; it is used afterward to verify the code.

Correct Answer: The "other specified" code

When a category has no unspecified code, the guidelines allow the "other specified" code to represent both other and unspecified. Codes titled "other" or "other specified" are otherwise used when the record gives detail for which no specific code exists. Option b is incorrect because the placeholder X only fills empty characters so a required 7th character sits in the correct position; it does not classify a condition. Option c is incorrect because an Excludes1 note marks codes that should not be reported together, so it says nothing about how to handle missing detail. Option d is incorrect because a 7th character extends codes in certain categories as the Tabular List instructs, and it does not replace a missing unspecified code.

Correct Answer: Assign only the combination code

A combination code classifies a diagnosis with an associated manifestation in a single code. When it clearly identifies all documented elements, the guidelines direct assignment of only that code, without multiple coding. Option a is incorrect because the combination code exists to classify a diagnosis together with its manifestation, so dropping the manifestation discards part of what a single code fully captures. Option b is incorrect because a secondary code is added only when the combination code lacks necessary specificity, and here the code already identifies every documented element. Option d is incorrect because multiple coding should not be used when the classification provides a combination code that clearly identifies all documented elements, which is the case here.

Correct Answer: Unspecified

The ICD-10-CM abbreviation conventions state that NOS, 'not otherwise specified,' is the equivalent of unspecified, in both the Alphabetic Index and the Tabular List. NEC is the abbreviation that represents 'other specified.' Option a is incorrect because sign and symptom codes report findings when no definitive diagnosis is established; the abbreviations section does not link NOS to them. Option b is incorrect because that meaning belongs to NEC, which signals that no specific code is available and directs the coder to the 'other specified' code. Option c is incorrect because the placeholder X fills empty characters so a 7th character sits in the correct position; it is not an abbreviation meaning.

Correct Answer: Keeping unsupported diagnosis codes submitted earlier after a chart review

OIG guidance lists failing to remove diagnosis codes previously submitted to CMS, when chart reviews show those codes were unsupported or invalid, as potentially fraudulent and abusive conduct found in federal investigations of risk adjustment. Option a is incorrect because CMS requires MAOs to have procedures for exactly this, which makes it a compliance measure rather than an investigated abuse. Option c is incorrect because CMS makes this the plan sponsor's responsibility, to be done as soon as possible after an internal review, so it is expected compliance conduct. Option d is incorrect because hospital outpatient facilities appear among the acceptable data sources in CMS guidance, alongside hospital inpatient facilities and physicians.

Correct Answer: The "other specified" code

When a category has no unspecified code, the guidelines allow the "other specified" code to represent both other and unspecified. Codes titled "other" or "other specified" are otherwise used when the record gives detail for which no specific code exists. Option a is incorrect because an Excludes1 note marks codes that should not be reported together, so it says nothing about how to handle missing detail. Option b is incorrect because a 7th character extends codes in certain categories as the Tabular List instructs, and it does not replace a missing unspecified code. Option c is incorrect because the placeholder X only fills empty characters so a required 7th character sits in the correct position; it does not classify a condition.

Correct Answer: The list is not necessarily exhaustive

ICD-10-CM guidelines state that inclusion terms are the conditions for which a code is used, but the list is not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to the code. Option b is incorrect because that describes an Excludes1 note, a pure excludes note meaning "NOT CODED HERE!" for conditions that cannot occur together, not inclusion terms. Option c is incorrect because the guidance says the terms are not necessarily exhaustive, and additional terms found only in the Alphabetic Index may also be assigned to the code. Option d is incorrect because placement immediately under a three-character code title belongs to Includes notes, whereas inclusion terms are listed under some codes more generally.

Correct Answer: Code them as related, based on the presumed causal relationship

The convention for "with" presumes a causal relationship between conditions linked in the Alphabetic Index or Tabular List. They are coded as related without explicit provider linkage unless documentation says they are unrelated or a guideline requires linkage. Option a is incorrect because an Excludes1 note covers two conditions that cannot occur together, such as congenital versus acquired forms, which is a different instruction from the 'with' convention. Option b is incorrect because documented linkage is required only for conditions not linked by relational terms, or where a specific guideline demands it; neither applies to this index entry. Option d is incorrect because the classification already presumes the relationship, so coding proceeds without extra provider documentation; no requirement to hold both conditions pending a query is stated.

Correct Answer: Do not code it without provider-indicated significance

Abnormal findings are not coded and reported unless the provider indicates their clinical significance. Here the provider ordered no further tests, gave no treatment, and made no comment, so the finding is not reported as an other diagnosis. Option b is incorrect because uncertain diagnosis rules apply to conditions qualified with terms such as probable or suspected at discharge, not to a lab value the provider never addressed. Option c is incorrect because history codes serve as secondary codes only when a historical condition or family history affects current care, which a new unaddressed lab result is not. Option d is incorrect because the outpatient practice for provider-interpreted diagnostic tests differs from inpatient practice, so applying it here would contradict the non-outpatient rule.

Correct Answer: I, III, and IV

Sequela coding generally uses two codes, with the condition or nature of the sequela first. No time limit applies, and multiple codes may describe complications and obstetric conditions. The acute-phase code is never reported with a sequela code. Option a is incorrect because it leaves out statement IV, yet the guidelines say multiple codes may be needed for complication and obstetric codes to fully describe a condition. Option b is incorrect because it includes statement II, but the guidelines state the code for the acute phase of the illness or injury is never used with a late effect code. Option c is incorrect because statement II is false because the acute-phase code is excluded, and this pairing also drops statements I and III, which the guidelines support.

Correct Answer: Add an organism code as a secondary code

A 'use additional code' note at a code outside an etiology/manifestation pair follows the same sequencing rule: a secondary code is added, if known. For bacterial infections, this is an organism code. Option a is incorrect because the organism code is sequenced after the infection code, since a 'use additional code' note makes it secondary rather than first. Option b is incorrect because a query is suggested for unclear Excludes1 relationships, whereas here the organism is already documented and the note gives a direct instruction. Option d is incorrect because the note exists because a secondary code is useful to fully describe the condition, so stopping at the infection code leaves the organism unreported.

Correct Answer: Code both, acute (subacute) code first

When the same condition is described as both acute (subacute) and chronic and separate subentries exist in the Alphabetic Index at the same indentation level, both codes are assigned, with the acute (subacute) code sequenced first. Option a is incorrect because a combination code classifies two diagnoses or a diagnosis with a manifestation or complication, which is a different situation from separate acute and chronic subentries. Option c is incorrect because separate subentries at the same indentation level allow both conditions to be reported, so dropping the chronic code leaves the documentation incompletely described. Option d is incorrect because the guideline reverses this order; the acute (subacute) code is sequenced ahead of the chronic code when both are reported.

Correct Answer: Assign an additional secondary code

The combination code guideline states that when a combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code to supply the missing detail. Option a is incorrect because acute phase codes are addressed in the sequela guideline, where the acute illness code is not used with a late effect code; it does not fix missing specificity. Option b is incorrect because the guidelines limit use of the combination code alone to cases where it fully identifies the diagnostic conditions, which is not the situation here. Option c is incorrect because the guidelines give no sequencing remedy for lacking specificity; they direct an additional code to be used as a secondary code instead.

Correct Answer: Assign only the combination code

A combination code classifies a diagnosis with an associated manifestation in a single code. When it clearly identifies all documented elements, the guidelines direct assignment of only that code, without multiple coding. Option a is incorrect because multiple coding should not be used when the classification provides a combination code that clearly identifies all documented elements, which is the case here. Option b is incorrect because a secondary code is added only when the combination code lacks necessary specificity, and here the code already identifies every documented element. Option d is incorrect because the combination code exists to classify a diagnosis together with its manifestation, so dropping the manifestation discards part of what a single code fully captures.