AAPC-CRC Certified Risk Adjustment Coder - Set 1 - Part 3

Correct Answer: I, II, and III

Adherence to the guidelines is required under HIPAA, the Cooperating Parties approve them, and the classification's instructions and conventions take precedence over guidelines. Only the approved set is official, so statement IV is false. Option a is incorrect because this pair omits statement III, which is also accurate because the classification's own instructions and conventions outrank the guidelines. Option c is incorrect because this combination leaves out statement I and adds statement IV, yet only the set approved by the Cooperating Parties is official. Option d is incorrect because statement IV is false, and this combination also drops statement II, since the four Cooperating Parties organizations do approve the guidelines.

Correct Answer: Assign the default code listed beside the main term

A code listed next to a main term in the Alphabetic Index is a default code, representing the most common or unspecified condition. When a condition is documented without additional information such as acute or chronic, the default code should be assigned. Option a is incorrect because code assignment rests on the provider's diagnostic statement, not on clinical criteria the coder applies to establish or refine the diagnosis. Option b is incorrect because a query is directed at conflicting documentation, and this record has no conflict, only a condition stated without added detail. Option c is incorrect because the guidelines do not let a coder infer a type of condition the provider has not documented; the listed default code covers this situation.

Correct Answer: Report codes for the signs and symptoms

When a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report sign and symptom codes in lieu of a definitive diagnosis, coding to the level of certainty known. Option a is incorrect because "other specified" codes apply when the record gives detail for which no specific code exists, and this record gives no such detail. Option c is incorrect because the guidelines name medically unnecessary diagnostic testing performed to determine a more specific code as inappropriate, so it cannot be the coder's remedy. Option d is incorrect because the guidelines call it inappropriate to select a specific code that the record documentation does not support, even when a condition seems probable.

Correct Answer: "Code first" note

The etiology/manifestation convention places a "code first" note at the manifestation code, directing that the underlying etiology be sequenced first and the manifestation listed after it. Option a is incorrect because it is placed at the etiology code, signaling that a manifestation code follows, rather than at the manifestation code itself. Option b is incorrect because it is an Alphabetic Index instruction pointing to another main term that may offer additional entries, not a Tabular List sequencing note. Option c is incorrect because it means "Not included here" and allows both conditions to be reported together; it does not set a sequencing order.

Correct Answer: bilateral

The laterality guideline directs the bilateral code for the first-side encounter because the condition still exists on both sides. A unilateral code follows only at the later encounter, once the treated side is free of the condition. Option a is incorrect because this code is reserved for rare cases where the record cannot show the affected side and clarification cannot be obtained, which does not apply here. Option b is incorrect because a sequela code describes a residual effect after the acute phase of an illness or injury, not laterality of a condition still present on both sides. Option d is incorrect because a unilateral code is assigned at the second encounter, once the first side no longer has the condition and only one side remains affected.

Correct Answer: Provider's documentation of the relationship between condition and care

The guideline on documentation of complications of care states that code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure, unless the classification instructs otherwise. Option a is incorrect because the guideline extends to any complications of care regardless of the chapter the code is located in, so chapter location is not the basis. Option c is incorrect because the guidelines state that not all conditions occurring during or following care are complications; a cause-and-effect relationship between the care and the condition must be documented. Option d is incorrect because the guidelines say the provider need not explicitly document the term "complication"; for example, a condition altering the course of surgery can qualify.

Correct Answer: Either condition may be sequenced first

When two or more interrelated conditions potentially meet the principal diagnosis definition, either may be sequenced first unless the circumstances of admission, therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise. Option a is incorrect because documentation order is not a sequencing criterion in the guideline, which looks to admission circumstances, therapy provided, the Tabular List and the Alphabetic Index. Option b is incorrect because the guideline gives no severity ranking for interrelated conditions; absent other direction it leaves the choice open rather than requiring the more severe one first. Option d is incorrect because the guideline already allows sequencing when no direction exists, so a query is not required before either condition is selected.

Correct Answer: A diagnosis may not be confirmed until two or more visits have occurred

The outpatient guidelines recognize that diagnoses often are not established at the first encounter or visit, and it may take two or more visits before the diagnosis is confirmed. Until then, symptom and sign codes are acceptable. Option b is incorrect because the outpatient guidelines state that inconclusive-diagnosis rules (probable, suspected, rule out) do not apply to outpatients, and symptom or sign codes are acceptable until the provider confirms a diagnosis. Option c is incorrect because the guidelines call beginning in the Alphabetic Index the most critical rule and warn that starting in the Tabular List leads to coding errors. Option d is incorrect because the guidelines say that definition does not apply to hospital-based outpatient services or provider-based office visits, where the term first-listed diagnosis is used in lieu of principal diagnosis.

Correct Answer: Report the confirmed diagnosis; do not code related signs and symptoms

For outpatient diagnostic tests interpreted by a physician, with the final report available at coding, the guidelines direct coding of the confirmed or definitive diagnosis. Related signs and symptoms are not coded as additional diagnoses. Option a is incorrect because the outpatient guidelines direct coding of the confirmed diagnosis from the interpretation, while related signs and symptoms are not added as additional diagnoses. Option c is incorrect because diagnoses documented as probable, suspected or similar uncertain terms are not coded in the outpatient setting; coding follows the highest degree of certainty. Option d is incorrect because that Z code applies to routine testing with no signs, symptoms or associated diagnosis, which does not fit a study ordered for chest pain.

Correct Answer: Data collection basic rule

Under the data collection basic rule in 42 CFR 422.310(b), each MA organization must submit to CMS, per CMS instructions, the data necessary to characterize the context and purposes of each item and service provided to an enrollee. Option b is incorrect because this is a format and delivery requirement, stating how data reach the appropriate CMS contractor, and says nothing about characterizing the items and services furnished. Option c is incorrect because these are optional contract terms the organization may use to require complete, accurate data from practitioners, rather than the duty to submit characterizing data to CMS. Option d is incorrect because this requirement addresses data accounting separately for each provider or practitioner permitted to bill separately under original Medicare, not the context and purposes of each item or service.