Chapter 9 — Quiz

Twenty-two questions.

Multiple choice

1. The Official Guidelines are approved by:

  • A. the American Medical Association
  • B. NCHS, CMS, AHA, and AHIMA
  • C. AAPC
  • D. individual Medicare Administrative Contractors

2. Adherence to the Official Guidelines is:

  • A. recommended
  • B. required
  • C. optional for outpatient coding
  • D. required only for facility claims

3. Section IV of the Guidelines governs:

  • A. inpatient admissions
  • B. outpatient services
  • C. all settings
  • D. conventions only

4. The first-listed diagnosis is determined by:

  • A. severity
  • B. the reason chiefly responsible for the services at this encounter
  • C. chronicity
  • D. the order the physician wrote them

5. The principal diagnosis is the condition established:

  • A. on admission
  • B. after study
  • C. by the emergency department
  • D. at the first encounter

6. In an office setting, "rule out pneumonia" should be:

  • A. coded as pneumonia
  • B. not coded; code the documented signs and symptoms
  • C. coded as pneumonia, unspecified
  • D. queried before any code is assigned

7. In an inpatient discharge summary, "probable pneumonia" should be:

  • A. not coded
  • B. coded as if established
  • C. coded as a symptom
  • D. queried

8. An emergency department encounter with discharge home is coded under:

  • A. Section II
  • B. Section III
  • C. Section IV
  • D. Section I only

9. A symptom integral to a confirmed disease is:

  • A. coded first
  • B. not coded separately
  • C. coded as a secondary diagnosis
  • D. coded only if severe

10. A symptom not routinely associated with the confirmed disease is:

  • A. not coded
  • B. coded
  • C. coded only in the inpatient setting
  • D. queried

11. Where the Alphabetic Index links two conditions under "with," the classification:

  • A. presumes a causal relationship
  • B. requires explicit documentation of a causal relationship
  • C. prohibits a combination code
  • D. requires a query

12. The "with" presumption is defeated by:

  • A. an unspecified code
  • B. documentation stating the conditions are unrelated
  • C. the absence of a combination code
  • D. an Excludes2 note

13. Same condition documented acute and chronic, separate index subentries at the same level:

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

14. In the conflict hierarchy, a chapter-specific guideline versus a general guideline:

  • A. the general guideline governs
  • B. the chapter-specific guideline governs
  • C. either may be used
  • D. query the provider

15. Which is not a tiebreaker when two rules conflict?

  • A. specific over general
  • B. Guidelines over conventions
  • C. which code pays more
  • D. Tabular over Index

Short answer

16. Name the four sections of the Guidelines and the setting each governs.

17. Explain in two sentences why the outpatient and inpatient uncertain-diagnosis rules are opposite.

18. Give both halves of the signs-and-symptoms rule, and say which half is forgotten.

19. State the "with" convention, its two boundaries, and what defeats it.

20. (Chapter 8) An Excludes1 note and a Guidelines exception appear to conflict. Which governs, and where does that sit in the §9.10 hierarchy?

21. (Chapter 4) Account 10-4471's assessment addresses three chronic conditions but not the chronic kidney disease on the problem list. Explain why E11.9 is correct, naming the two distinct questions involved.

22. A coding question cannot be resolved from the Guidelines, the conventions, or Coding Clinic. What do you do, and what makes the decision defensible?

Answer key **1.** B. **2.** B. **3.** B. **4.** B. **5.** B. **6.** B. **7.** B. **8.** C — the emergency department is **outpatient**, which is the most common setting trap. **9.** B. **10.** B. **11.** A. **12.** B. **13.** C. **14.** B. **15.** C. **16.** **Section I** — conventions, general guidelines, chapter-specific guidelines; **all settings**. **Section II** — selection of principal diagnosis; **inpatient**. **Section III** — reporting additional diagnoses; **inpatient**. **Section IV** — outpatient services. **17.** The outpatient rule protects the patient and the record: an office visit is a snapshot, coding a guess as established puts a disease on a permanent record, and documented symptoms are usually available to code instead. The inpatient rule captures the workup: an admission consumed substantial resources pursuing a diagnosis, and coding only symptoms would describe that as though nothing had been determined. **Each codes what its setting actually establishes.** **18.** **Integral** signs and symptoms are **not** coded separately when a definitive diagnosis is established. **Non-integral** ones — not routinely associated with the documented disease — **are** coded. **The second half is forgotten**, and forgetting it loses information; under risk adjustment it can lose money. **19.** Where "with" or "in" links two conditions in a code title, the Alphabetic Index, or a Tabular instructional note, **the classification presumes a causal relationship**, and the conditions are coded as related even without explicit provider documentation. **Boundaries:** it applies only where the *classification* creates the link — not wherever "with" appears in a note — and it does not extend to pairings the classification has not made. **It is defeated by** documentation clearly stating the conditions are unrelated. **20.** **The Guidelines govern.** An Excludes1 note is a **convention** printed in the code book; the Guidelines sit above the conventions. In the §9.10 hierarchy this is level 2 — Guidelines over conventions — and Chapter 8's Case Study 1 is the documented instance of it. **21.** **Two questions.** (1) *May diabetes and CKD be linked without an explicit provider statement?* The "with" convention says yes — the presumption is available. (2) *Was the CKD addressed, affecting treatment, or requiring management at this encounter?* Section IV asks this, and the assessment addresses diabetes, hypertension, and hyperlipidemia and **not** the kidney disease. **The second question is doing the work.** A coder reporting E11.22 + N18.31 has answered the linkage question correctly and skipped the addressed question entirely. **22.** Make a decision, **write down the reasoning**, and be able to produce it. The order is: Guidelines → conventions → Coding Clinic → your MAC → a documented decision. **What makes it defensible is the documentation of the reasoning**, not the answer — an ambiguity you documented is defensible, and the same ambiguity undocumented is indistinguishable from carelessness two years later.