Question 1

In the inpatient setting, the physician documents possible aspiration pneumonia in the discharge summary.The aspiration pneumonia is coded as if it exists.

Accepted Answer

The physician documented possible aspiration pneumonia in the discharge summary, therefore it should be coded as if it exists.

Question 2

A significant procedure is one that:

Accepted Answer

A significant procedure is one that carries an anesthetic risk, is surgical in nature, and requires specialized training. Therefore, all of the choices provided are correct.

Question 3

Patient is admitted following an outpatient procedure because of an exacerbation of the patient's asthma.What is the principal diagnosis?

Accepted Answer

The principal diagnosis should be the condition that was primarily responsible for the patient's admission to the hospital. In this case, the exacerbation of the patient's asthma is the reason for the admission, so it should be the principal diagnosis. The reason for the outpatient procedure, cancellation of the procedure, and aftercare codes are not relevant to the reason for the current admission.

Question 4

The use of a POA indicator is required for all acute-care facilities that are reimbursed under MS-DRGs.

Accepted Answer

The use of a POA (present on admission) indicator is required for all acute-care facilities that are reimbursed under MS-DRGs (Medicare Severity Diagnosis-Related Groups). This helps to determine if a particular condition was present at the time of admission or if it was acquired during the hospital stay, which can affect reimbursement rates.

Question 5

Patient is admitted with dysuria due to a severe urinary tract infection.Which diagnoses should be reported?

Accepted Answer

The primary diagnosis is urinary tract infection, and dysuria is a symptom of that condition. Only the primary diagnosis needs to be reported.

Question 6

The removal of a tooth is an example of an extraction in the ICD-10-PCS system.

Accepted Answer

The removal of a tooth is indeed an example of an extraction procedure in the ICD-10-PCS system.

Question 7

A principal procedure is one that is performed for definitive treatment rather than for diagnostic or exploratory purposes, or one necessary to take care of a complication.

Accepted Answer

A principal procedure is indeed one that is performed for definitive treatment or to take care of a complication, rather than for purely diagnostic or exploratory purposes.

Question 8

In the inpatient setting, a procedure code from ICD-10-PCS would be assigned to identify a procedure.

Accepted Answer

In the inpatient setting, procedures are identified using procedure codes from ICD-10-PCS.

Question 9

The Tabular List of ICD-10-PCS contains grids that represent the last four characters of a procedure code.

Accepted Answer

The Tabular List of ICD-10-PCS contains grids that represent the last four characters of a procedure code, which provide additional details about the approach, device, qualifier, and/or body part involved in the procedure.

Question 10

The ICD-10-PCS has a seven-character alphanumeric code structure.

Accepted Answer

The ICD-10-PCS does have a seven-character alphanumeric code structure, consisting of a combination of letters and numbers that specify various aspects of a medical procedure.

Question 11

The discharge summary states the patient's diagnosis is acute abdominal pain due to peptic ulcer disease or cholecystitis.Which diagnoses should be reported?

Accepted Answer

All three diagnoses mentioned in the discharge summary should be reported to accurately reflect the patient's condition and treatment.

Question 12

The American Hospital Association is responsible for the development of ICD-10-PCS.

Accepted Answer

The American Hospital Association was a collaborator in the development of ICD-10-PCS, but it was actually developed by the Centers for Medicare & Medicaid Services (CMS).

Question 13

The Centers for Medicare and Medicaid Services (CMS) is responsible for the development of ICD-10-PCS.

Accepted Answer

This statement is true. The Centers for Medicare and Medicaid Services (CMS) is responsible for the development of ICD-10-PCS.

Question 14

In the inpatient setting, a CPT code would be assigned for a procedure code.

Accepted Answer

The answer of In the inpatient setting, a CPT code...

Question 15

The discharge summary states the patient's diagnoses are peptic ulcer disease versus chronic cholecystitis.Which diagnoses should be reported?

Accepted Answer

Both peptic ulcer disease and chronic cholecystitis should be reported because either one can be the principal diagnosis depending on the circumstances of the admission.

Question 16

It is unacceptable to assign codes in the inpatient setting to diagnoses that are documented as being "probable," "suspected," or "likely."

Accepted Answer

In the inpatient setting, it is acceptable to code diagnoses that are documented as "probable," "suspected," "likely," or similar terms when the clinical evaluation, diagnostic procedures, or other types of examinations support these diagnoses as the cause of the patient's illness or condition during the hospital stay.

Question 17

The principal diagnosis is defined as the most serious condition during a patient's hospital stay.

Accepted Answer

The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Question 18

When two or more diagnoses equally meet the definition for principal diagnosis, either one can be selected as the principal diagnosis.

Accepted Answer

According to the guidelines of the International Classification of Diseases (ICD), when two or more diagnoses meet the definition for principal diagnosis, either one can be selected as the principal diagnosis based on the circumstances of the admission, the diagnostic workup, and the treatment provided. However, the selection of the principal diagnosis should reflect the reason for admission and the condition that was chiefly responsible for the services provided.

Question 19

The Official Guidelines for Coding and Reporting are updated every year.

Accepted Answer

The Official Guidelines for Coding and Reporting are updated annually to reflect changes in medical coding and documentation practices.

Question 20

In the inpatient setting, the principal diagnosis is also called the "first-listed" diagnosis.

Accepted Answer

In the inpatient setting, the principal diagnosis is defined as the condition established after study to be chiefly responsible for the patient's admission to the hospital, whereas the "first-listed" diagnosis is a term used in the outpatient setting.

Quiz 27: Inpatient Coding