Domain 4 question 1st test Flashcards
Which of the following coding error classifications is most valuable in determining the impact on overall revenue cycle?
a. errors by coding guideline
b. percentage of cases that could have been improved if queried
c. errors by coding professional
d. errors that produced changes in MS-DRG assignment
errors that produced changes in MS-DRG assignment
A patient was seen in the emergency department for chest pain. It was suspected that the patient may have gastrosophageal reflux disease (GERD). The final diagnosis was “Rule out GERD.” The correct ICD-10-CM diagnosis code is:
K21.9, Gastro-esophageal reflux disease without esophagitis
R07.9, Chest pain, unspecified
R10.11, Right upper quadrant pain
Z03.89, Encounter for observation for other suspected diseases and conditions ruled out
R07.9, chest pain, unspecified
Because this patient was seen only in the emergency department, he or she would be classified as an outpatient.
Diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” “working diagnosis,” or other
similar terms in the outpatient setting indicate uncertainty and would not be coded as if existing. Rather, code the condition to the highest degree of certainty for that encounter or visit, such as signs, symptoms, abnormal test results, or other reason for the visit. In this case, unspecified chest pain would be coded (Schraffenberger and Palkie 2022, 105).
A patient has liver metastasis due to adenocarcinoma of the rectum. The rectum was resected two years ago. The patient has been receiving radiotherapy to the liver with some relief of pain.
The patient is being admitted at this time for management of severe anemia due to the malignancy. The principal diagnosis listed on this admission is:
Liver metastasis
Adenocarcinoma of the rectum
Anemia
Admission for radiotherapy
Liver metastasis
When an admission or encounter is for the management of anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced first as the principal or first-listed diagnosis followed by the appropriate code for the anemia (such as D63.0, Anemia in neoplastic disease) according to ICD-10-CM Coding Guideline 1.C.2.c. 1 (Schraffenberger and Palkie 2022, 147-148).
The determination of the reimbursement amount based on the beneficiary’s insurance plan benefits is called:
Charge capture
Adjudication
Adjustment
Revenue management
Adjudication
is the determination of the reimbursement amount based on the beneficiary’s insurance plan benefits. When clean claims are submitted, electronic adjudication can occur. Four outcomes may occur from adjudication: payment, suspend, reject, or deny. If the outcome is payment, then the reimbursement for the claim is paid without review or further processing (Casto and White 2021, 170).
The discharged, not filed billed report is a daily report used to track accounts that are:
Awaiting payment in accounts receivable
Paid at different rates
( In bill hold or in error and awaiting billing
Pulled for quality review
In bill hold or in error and awaiting billing
The accounts not selected for billing report is a daily report used to track the many reasons that accounts may not be ready for billing. This report is also called the discharged, not final billed (DNFB) report. Accounts that have not met all facility-specified criteria for billing are held and reported on this daily tracking list. Some accounts are held because the patient has not signed the consents and authorizations required by the insurer.
Still others are not billed because the primary and secondary insurance benefits have not been confirmed (Schraffenberger and Kuehn 2011, 436; AHIMA 2017, 81).
Which of the following is a function of the outpatient code editor?
Validate the patient’s gender with the procedure codes
Validate the patient’s encounter number
Identify unbundling of codes
Identify cases that do not meet medical necessity
Validate the patient’s gender with the procedure codes
The Medicare Outpatient Code Editor (OCE) is a software program designed to process data for the Medicare Hospital Outpatient Payment System pricing and to audit facility claims data. The OCE audits claims for coding and data entry errors. The extensive edits in the OCE are applied to claims, individual diagnoses and procedures, and code sets. The procedure and sex conflict edit occurs when the sex of the patient does not match the sex designated for the procedure code reported (Casto and White 2021, 218-219).
The coding professional assigned separate codes for individual tests when a combination code exists. This is an example of which of the following?
Upcoding
Complex coding
Query
Unbundling
Unbundling
Unbundling occurs when individual components of a complete procedure or service are billed separately instead of using a combination code (Bowman 2017, 440).
Joe Carlson was admitted to Community Hospital. Two days later, he was transferred to Big Medical Center for further evaluation and treatment. He was discharged to home after three days with a qualified transfer DRG from Big Medical Center. Community Hospital will receive from Medicare:
The full DRG amount, and Big Medical Center will receive a per diem rate for the three-day stay
A per diem rate for the two-day stay, and Big Medical Center will receive the full DRG payment
The full DRG amount, and Big Medical Center will bill Community Hospital a per diem rate for the three-day stay
No payment; Community Hospital must bill Big Medical Center a per diem rate for the two-day stay
A per diem rate for the two-day stay, and Big Medical Center will receive the full DRG payment
There are two types of transfer cases under the inpatient prospective payment system (IPPS). The first category is a patient transfer between two IPPS hospitals. A type 1 transfer is when a patient is discharged from an acute IPPS hospital (Community Hospital in this case) and is admitted to another acute IPPS hospital (Big Medical Center) on the same day. Payment is altered for the transferring hospital and is based on a per diem rate methodology. The transferring facility receives double the per dim rate for the first day plus the per diem rate for each day thereafter for the patient LOS. The receiving facility receives the full PPS payment rate for the case (Casto and White 2021, 80).
Which of the following individuals assists in educating medical staff members on the documentation needed for accurate coding?
Physician champion
Compliance officer
Chargemaster coordinator
Data monitor
Physician champion
The health information manager must continuously promote complete, accurate, and timely documentation to ensure appropriate coding, billing, and reimbursement. This requires a close working relationship with the medical staff, perhaps through the use of a physician champion. Physician champions assist in educating medical staff members on documentation needed for accurate billing. The medical staff is more likely to listen to a peer than to a facility employee, especially when the topic is documentation needed to ensure appropriate reimbursement (Hess 2015, 123).
Patient accounting is reporting an increase in national coverage decisions (NCDs) and local coverage determinations (LCDs) failed edits in observation accounts. Which of the following
departments will be tasked to resolve this issue?
Health information management
Patient access
Patient accounts
Utilization management
HIM
Resolving failed edits is one of many duties of the health information management (HIM) department. Various
hospital departments depend on the coding expertise of HIM professionals to avoid incorrect coding and
potential compliance issues (Casto and White 2021, 167-168).
A patient had a placenta previa with delivery of twins. The patient had two prior cesarean sections. This was an emergency C-section due to hemorrhage. The appropriate principal diagnosis would be:
Normal delivery
Placenta previa
Twin gestation
Vaginal hemorrhage
Placenta previa
In cases of a cesarean delivery, the selection of the principal diagnosis should be the condition established after study that was responsible for the patient’s admission. If the patient was admitted with a condition that resulted in the performance of the cesarean procedure, that condition should be selected as the principal diagnosis. If the reason for the admission or encounter was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission or encounter should be selected as the principal diagnosis even if a cesarean was performed (Schraffenberger and Palkie 2022, 493).
A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. Which of the following would be the correct sequencing and coding of this case?
Congestive heart failure, respiratory failure, ventilator management, intubation
Respiratory failure, intubation, ventilator management
Respiratory failure, congestive heart failure, intubation, ventilator management
Shortness of breath, congestive heart failure, respiratory failure, ventilator management
Congestive heart failure, respiratory failure, ventilator management, intubation
CH is the principal diagnosis and must be sequenced first as shortness of breath is a symptom of CH, and the respiratory failure is a result of the CHF. The principal diagnosis is the reason for the admission to the hospital after study (Schraffenberger and Palkie 2022, 95).
Placenta previa with delivery of twins. This patient had two prior cesarean sections. She also has a third-degree perineal laceration. This was an emergent C-section due to hemorrhage associated with the placenta previa. The appropriate principal diagnosis would be:
Third-degree perineal laceration
Placenta previa
Twin gestation
Vaginal hemorrhage
Placenta previa
Placenta previa is the reason for the C-section and therefore is the principal diagnosis (Schraffenberger and Palkie 2022, 493).
A skin lesion was removed from a patient’s cheek in the dermatologist’s office. The dermatologist documents skin lesion, probable basal cell carcinoma. Which of the following actions should the coding professional take to code this encounter?
Code skin lesion.
Code benign skin lesion.
Code basal cell carcinoma.
Query the dermatologist.
Code skin lesion
In the outpatient setting, do not code a diagnosis documented as “probable.” Rather, code the conditions to the highest degree of certainty for the encounter (Schraffenberger and Palkie 2022, 105).
A patient is admitted for the treatment of dehydration secondary to chemotherapy for primary liver cancer. Intravenous (IV) fluids were administered to the patient. Which of the following should be sequenced as the principal diagnosis?
Dehydration
Chemotherapy
Liver carcinoma
Complication of chemotherapy
Dehydration
When the admission or encounter is for management of dehydration due to the malignancy and only the dehydration is being treated, the dehydration is sequenced first, followed by the code(s) for the malignancy (Schraffenberger and Palkie 2022, 148).
