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

Correct Answer: Not assigned as additional codes, unless the classification instructs otherwise

Signs and symptoms that are associated routinely with a disease process are integral to it, so they should not be assigned as additional codes unless the classification instructs otherwise. Option a is incorrect because substituting symptom codes is acceptable only when a related definitive diagnosis has not been established, whereas here the disease process is already confirmed by the provider. Option b is incorrect because the guidelines call for a query when documentation conflicts or a borderline condition is unclear, and give no such step for routine symptoms. Option c is incorrect because that is the instruction for additional signs and symptoms not routinely associated with the disease process; routinely associated ones are excluded from additional coding.

Correct Answer: The coder verifies that the documented clinical criteria support the provider's diagnosis before assigning the code.

Code assignment rests on the provider's diagnostic statement that the condition exists. It is not based on the clinical criteria the provider used to establish the diagnosis, so a coder does not verify those criteria first. Option a is incorrect because the guidelines assign this step to the provider, so a query is the prescribed response when the record contradicts itself, not coder judgment. Option b is incorrect because it restates the guideline directly, since the provider's diagnostic statement that the condition exists is what supports assigning the code, with nothing further required. Option d is incorrect because this matches the default code convention, under which a bare diagnosis such as appendicitis is assigned the code listed next to the main term in the Alphabetic Index.

Correct Answer: ask the provider whether to add the finding

In non-outpatient settings, abnormal findings are not coded unless the provider indicates clinical significance. When findings fall outside the normal range and the provider ordered other tests or prescribed treatment, the coder may ask whether the finding should be added. Option b is incorrect because previous conditions are resolved diagnoses or status-post procedures from earlier admissions with no bearing on the stay, a separate category from abnormal findings. Option c is incorrect because abnormal findings are not coded or reported unless the provider indicates clinical significance, and an out-of-range value with follow-up testing does not replace that indication. Option d is incorrect because the guidance notes that non-outpatient practice differs from outpatient coding for diagnostic tests interpreted by a provider, so those rules do not govern this situation.

Correct Answer: Assign the code using the nurse's documentation

When the patient's provider does not document laterality, code assignment for the affected side may be based on medical record documentation from other clinicians, such as nursing staff, provided the record does not conflict. Option a is incorrect because unspecified-side codes should rarely be used, such as when the record is insufficient to determine the side and clarification cannot be obtained. Option b is incorrect because a query is called for when record documentation conflicts about the affected side, and here nothing conflicts. Option d is incorrect because separate codes for both sides apply when a condition is bilateral and no bilateral code exists, which is not the situation described.

Correct Answer: ask the provider whether to add the finding

In non-outpatient settings, abnormal findings are not coded unless the provider indicates clinical significance. When findings fall outside the normal range and the provider ordered other tests or prescribed treatment, the coder may ask whether the finding should be added. Option a is incorrect because the guidance notes that non-outpatient practice differs from outpatient coding for diagnostic tests interpreted by a provider, so those rules do not govern this situation. Option b is incorrect because previous conditions are resolved diagnoses or status-post procedures from earlier admissions with no bearing on the stay, a separate category from abnormal findings. Option c is incorrect because abnormal findings are not coded or reported unless the provider indicates clinical significance, and an out-of-range value with follow-up testing does not replace that indication.

Correct Answer: Report the code once for the encounter

Under the guideline on reporting the same diagnosis code more than once, each unique ICD-10-CM diagnosis code may be reported only once for an encounter, including when two different conditions are classified to the same code. Option b is incorrect because unspecified-side codes address missing laterality in the record and should rarely be used; they do not resolve two conditions sharing one code. Option c is incorrect because a sequela is the residual effect after the acute phase of an illness or injury, which is not what two conditions sharing a code represent. Option d is incorrect because the guideline allows each unique diagnosis code to be reported only once per encounter, and that limit covers two different conditions classified to one code.

Correct Answer: Cause-and-effect relationship

The guideline on documentation of complications of care requires a cause-and-effect relationship between the care provided and the condition, along with documentation that the condition is clinically significant. Occurring during or after care is not enough. Option a is incorrect because the guideline extends to complications of care regardless of the chapter in which the code is located, so chapter placement does not define the link. Option c is incorrect because integral refers to manifestations that are part of a disease process in the syndrome guidance, not to the link between care and a condition. Option d is incorrect because timing alone is not what the guideline requires; a condition occurring during or following care is not automatically classified as a complication.

Correct Answer: Health Insurance Portability and Accountability Act (HIPAA)

The guidelines state that adherence when assigning ICD-10-CM 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 WHO publishes the ICD-10 on which ICD-10-CM is based, but it is not the U.S. authority requiring adherence to these guidelines. Option b is incorrect because the Cooperating Parties are four organizations that approved the guidelines, not a law; they do not create the legal requirement to follow them. Option c is incorrect because DHHS houses CMS and NCHS, which provide the guidelines, yet the guidance ties the adherence requirement to HIPAA rather than to DHHS itself.

Correct Answer: Report a complication code because the condition altered the surgery

Guideline on Documentation of Complications of Care says the provider need not explicitly document the term "complication." A condition that alters the course of surgery, as documented in the operative report, supports reporting a complication code. Option a is incorrect because a query is called for only when documentation is unclear about the relationship between condition and care, and the operative report here makes it clear. Option b is incorrect because sign and symptom codes apply when no diagnosis is established, but here the documented effect on the surgical course supports a complication code instead. Option d is incorrect because the guidelines state the provider need not explicitly document the term "complication," so missing wording does not bar reporting a complication code.

Correct Answer: The medical condition that led to the hospital admission

For an admission following medical observation, the principal diagnosis is the medical condition that led to the hospital admission, because the same condition worsened or did not improve and resulted in the inpatient admission. Option b is incorrect because symptom-first sequencing is not what the guideline directs; it names the medical condition that led to the admission, not an initial presenting symptom. Option c is incorrect because this rule belongs to admissions from outpatient surgery when no complication or other condition is documented, not to admissions following medical observation. Option d is incorrect because that choice applies only in rare cases where diagnoses are documented as either/or; here one medical condition worsened or did not improve.

Correct Answer: Hospice services at all levels of care

The UHDDS definitions were expanded to all non-outpatient settings, such as home health agencies, rehab facilities and nursing homes, and the guidelines also state that they apply to hospice services at all levels of care. Option a is incorrect because clinic visits are outpatient encounters, so they are not among the non-outpatient settings named when the UHDDS application was expanded. Option b is incorrect because outpatient surgery is handled by its own rules, and only a later inpatient admission from it follows the principal diagnosis guidance; the surgery itself is not a listed setting. Option c is incorrect because the guidelines extend the UHDDS definitions to non-outpatient settings, and a physician office visit is an outpatient encounter that falls outside that expansion.

Correct Answer: I and III

The circumstances of inpatient admission always govern principal diagnosis selection, and the UHDDS definitions have been expanded to all non-outpatient settings, including hospice services at all levels of care. Statements I and III are correct. Option b is incorrect because statement II reverses the guideline, which bars symptom, sign and ill-defined condition codes as principal diagnosis once a related definitive diagnosis is established. Option c is incorrect because both statements are wrong: definitive diagnoses outrank symptom codes, and rehabilitation admissions are sequenced by the condition being treated, not by specialty. Option d is incorrect because statement III is right, but statement IV invents a specialty rule; the guideline sequences the condition for which rehabilitation is performed, or aftercare or injury codes.

Correct Answer: The condition for which the service is performed

When the purpose for the admission or encounter is rehabilitation, the guidelines direct that the condition for which the rehabilitation service is being performed is sequenced first, as the first-listed or principal diagnosis. Option a is incorrect because a complication is sequenced first only when the admission is for treatment of that complication, which is a different circumstance from a rehabilitation admission. Option b is incorrect because this applies to an inpatient admission following outpatient surgery when no complication or other condition is documented, not to an admission for rehabilitation. Option d is incorrect because symptom and sign codes are not used as principal diagnosis once a related definitive diagnosis has been established, and rehabilitation is directed at the underlying condition.

Correct Answer: First-listed diagnosis

In the outpatient setting, the ICD-10-CM guidelines use the term first-listed diagnosis in lieu of principal diagnosis, because the UHDDS definition of principal diagnosis does not apply to provider-based office visits. Option a is incorrect because highest level of specificity is a rule about how precisely a code is chosen when documentation supports it, not a name for the lead diagnosis. Option b is incorrect because the guidelines use additional codes for coexisting conditions listed after the reason for the visit, so this term describes later codes rather than the lead one. Option c is incorrect because this is the heading for diagnoses documented as probable or suspected, which are not coded in outpatient settings; it names a coding restriction, not a sequencing term.

Correct Answer: Code the symptom, not the suspected condition

The outpatient guideline says not to code diagnoses documented as "probable," "suspected," or "rule out." The coder reports the condition to the highest degree of certainty for that encounter, such as a symptom or sign. Option b is incorrect because this is the inpatient approach for short-term, acute, long-term care and psychiatric hospital admissions, and it does not apply to outpatient encounters. Option c is incorrect because the outpatient guideline directs coding to the highest degree of certainty for that encounter, such as symptoms or signs, rather than delaying the report. Option d is incorrect because coding the suspected condition is barred by the outpatient guideline, so reporting it alongside the symptom would still break the uncertain diagnosis rule.

Correct Answer: current care

The guidelines allow history codes as secondary codes when the historical condition or family history has an impact on current care or influences treatment. Without such an impact, previous conditions with no bearing on the stay are not reported. Option a is incorrect because a diagnosis listed in the final diagnostic statement should ordinarily be coded, but that placement is not the condition for using a history code. Option c is incorrect because hospital policy is what may require coding of resolved conditions or status-post procedures with no bearing; it is not the test for secondary history codes. Option d is incorrect because conditions relating to an earlier episode with no bearing on the current stay are excluded, so impact on that episode would not justify reporting.

Correct Answer: Go to the referenced main term

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 to locate the correct code. Option a is incorrect because the search begins in the Alphabetic Index, and a "see" note sends the coder to another main term within the Index, not to the Tabular List. Option b is incorrect because optional following applies to a "see also" note, which can be skipped when the original main term provides the code; a "see" note is necessary. Option d is incorrect because the "see" instruction states that another term should be referenced, so the original main term alone does not lead to the correct code.

Correct Answer: Exclude them as earlier-episode diagnoses with no bearing

The UHDDS definition of other diagnoses excludes diagnoses that relate to an earlier episode and have no bearing on the current stay. Resolved conditions and status-post procedures like these are not reported, unless hospital policy requires it. Option b is incorrect because abnormal findings concern laboratory, x-ray and pathologic results and clinical significance, which is a separate rule from previous conditions. Option c is incorrect because a provider's listing alone does not decide reporting; resolved conditions and status-post procedures with no bearing on the current stay are not reported. Option d is incorrect because the uncertain diagnosis guideline covers terms like probable or suspected at discharge; these conditions are resolved or past, not uncertain.

Correct Answer: The condition that occasioned the admission after study

Under the guideline for an original treatment plan not carried out, the principal diagnosis is the condition that, after study, occasioned the admission, even though treatment may not have been carried out due to unforeseen circumstances. Option a is incorrect because symptom codes from Chapter 18 are not used as principal diagnosis once a related definitive diagnosis has been established after study. Option b is incorrect because the number of related secondary diagnoses is not a selection criterion; the UHDDS definition focuses on the condition chiefly responsible for occasioning the admission. Option d is incorrect because the guideline for an original treatment plan not carried out states that treatment may not have occurred, so selection does not depend on treatment given.

Correct Answer: Two codes may be required, with sequencing based on encounter circumstances

A 'code also' note instructs that two codes may be required to fully describe a condition, but it gives no sequencing direction. The order depends on the circumstances of the encounter. Option a is incorrect because that describes an Excludes1 note, which means 'NOT CODED HERE!' for conditions that cannot occur together, a different convention. Option c is incorrect because giving examples of a category's content is the job of an Includes note, which sits under a three-character code title. Option d is incorrect because the guidelines give no fixed order for this note; they say sequencing depends on the circumstances of the encounter, not on position.