Chapter 9 — Exercises

Items marked † have worked solutions in Answers to Selected Exercises, along with every odd-numbered item.

Work these with the current Official Guidelines open. They are free and this chapter is an argument for reading them.

A. Recall and vocabulary

9.1 What are the Official Guidelines, who approves them, and what is their status?

9.2 Name the four sections and state which setting each governs.

9.3 † State the definition of the first-listed diagnosis. What determines it, and what explicitly does not?

9.4 State the definition of the principal diagnosis. Which two words do the work, and why?

9.5 † State the uncertain-diagnosis rule for both settings. Then explain why they differ, in terms of what each setting establishes.

9.6 Give both halves of the signs-and-symptoms rule. Which half do people forget, and what does forgetting it cost?

9.7 † State the "with" convention. Then state the two boundaries that limit it and the one thing that defeats it.

9.8 Name the three conditions that must all hold before you report both an acute and a chronic code for the same condition.

9.9 Name five things that fix sequencing.

9.10 † State the conflict-resolution hierarchy in §9.10, in order. What is deliberately absent from it?

B. Apply the rules

9.11 † For each, state what you code. Identify the setting first.

(a) Office visit. "Chest pain, rule out GERD." (b) Inpatient discharge summary. "Probable pneumonia, treated empirically." (c) Emergency department, patient discharged home. "Possible appendicitis; abdominal pain, nausea." (d) Office visit. "Chest pain, likely musculoskeletal — GERD confirmed by prior endoscopy, ongoing."

9.12 A patient with confirmed acute cholecystitis has documented right upper quadrant pain, nausea, and — separately — a new documented tremor. Which symptoms do you code?

9.13 † A clinic note documents "acute on chronic systolic heart failure." The index provides separate subentries for acute and for chronic at the same indentation level. What do you code and in what order?

9.14 A patient is seen for a diabetic foot ulcer. The provider documents "diabetes" and "foot ulcer" without stating a relationship. The Alphabetic Index links them under "with." May you code the combination?

9.15 † A patient has type 2 diabetes and osteoarthritis of the knee. The provider does not link them. May you code them as related? Explain the difference between this item and 9.14.

9.16 A provider documents "the patient's chronic kidney disease is not related to her diabetes." The Index links the two under "with." What do you code?

9.17 † A patient is seen for a routine chronic-disease follow-up and mentions, in passing, a new symptom the provider examines and addresses. Which is the first-listed diagnosis? What additional information would change your answer?

9.18 A chapter-specific guideline in Section I.C requires explicit provider documentation of a causal relationship for a particular pairing. The Alphabetic Index links the same conditions under "with." Which governs?

C. Read the document

9.19 † An office note's assessment reads, in full:

  1. Cough, fever, and shortness of breath. Chest x-ray ordered.
     Rule out pneumonia. Empiric antibiotics started.

State every code you would assign and every code you would not, with the rule for each.

9.20 An inpatient discharge summary's final diagnoses read:

  1. Probable aspiration pneumonia
  2. Acute on chronic diastolic heart failure
  3. Type 2 diabetes mellitus
  4. Hypertension

Which of these four is affected by a Section II rule that would not apply in a clinic? What do you do with it?

9.21 † A claim is denied for medical necessity. The claim carries four diagnosis codes, and the one supporting the service is listed fourth. State the likely cause, the fix, and the chapter that covers the mechanism that would have prevented it.

D. Judgment and process

9.22 A colleague says the Guidelines are "just recommendations." Give the three-part response.

9.23 † A risk-adjustment vendor's coder tells you that the "with" convention permits linking any two conditions where a clinical relationship is plausible. Explain precisely what is wrong with that, and name the exposure.

9.24 You cannot resolve a coding question from the Guidelines, the conventions, or Coding Clinic. Describe what you do, in order, and state what makes your eventual decision defensible.

9.25 † A practice's coders have never read the Guidelines. Write the case to a practice manager for spending one afternoon on it, including what you would expect it to change.

9.26 Under what circumstances is it correct to code a symptom when a definitive diagnosis has been established? Give two distinct circumstances.

E. Certification-style questions

9.27 † In the outpatient setting, a diagnosis documented as "probable" should be:

  • A. coded as if established
  • B. not coded; code the signs, symptoms, or reason for the encounter
  • C. queried in all cases
  • D. coded with an unspecified code

9.28 The principal diagnosis is defined as the condition:

  • A. that is most severe
  • B. established after study to be chiefly responsible for occasioning the admission
  • C. treated during the stay
  • D. listed first by the physician

9.29 † Signs and symptoms integral to a confirmed disease process are:

  • A. always coded
  • B. not coded separately
  • C. coded only in the inpatient setting
  • D. coded as additional diagnoses

9.30 Where the Alphabetic Index links two conditions with the word "with," the classification:

  • A. requires explicit provider documentation of a causal relationship
  • B. presumes a causal relationship
  • C. prohibits reporting both
  • D. requires a query in all cases

9.31 † When the same condition is documented as both acute and chronic and separate index subentries exist at the same indentation level:

  • A. code only the chronic condition
  • B. code only the acute condition
  • C. code both, acute first
  • D. code both, chronic first

9.32 Sections II and III of the Official Guidelines apply to:

  • A. all settings
  • B. outpatient encounters
  • C. inpatient admissions
  • D. emergency department encounters

9.33 † A patient is seen in the emergency department and discharged home. The setting for coding purposes is:

  • A. inpatient
  • B. outpatient
  • C. observation
  • D. determined by length of stay

F. Write it

9.34 † Write, in under 120 words, the explanation you would give a new coder of why the outpatient and inpatient uncertain-diagnosis rules are opposite. It must explain the reason, not just state both rules.

9.35 Draft the one-paragraph note you would put in a practice's coding policy stating how unresolvable coding questions are decided and documented.

9.36 Write the "with" convention as a two-sentence rule you could apply under time pressure, including the boundary.

G. The Encounter

9.37 † State why M25.561 is the correct code for March 14 under §9.6, quoting the note. Then state what would have to be documented for a different code to be correct.

9.38 The chapter says the claim's diagnosis sequencing is "one of the genuinely free choices §9.9 describes." Construct the argument for sequencing E11.9 first instead, and then say what is not free about the sequencing regardless.

9.39 † Explain, in your own words and precisely, why E11.9 rather than E11.22 + N18.31 is correct for March 14. Your answer must identify two distinct questions and say which one is doing the work.

9.40 The chapter says the March 14 code is "not wrong; it is incomplete as a description of the patient." Explain how a code can be both correct and incomplete, and name the payment model under which the distinction becomes expensive.

9.41 Update your Encounter Workbook (Appendix C): record the first-listed diagnosis decision, the symptom-code justification, and the two-question analysis of the diabetes line.