CBCS Coding and Coding Guidelines 2 — Questions and Answers
Question 1: In CPT E/M coding for office visits, which three key components determine the level of service for new patients?
- History, physical exam, and medical decision making — all three must meet or exceed the level (Correct answer)
- History, chief complaint, and vital signs
- Medical decision making, time, and diagnosis
- Physical exam, ROS, and assessment
Correct answer: History, physical exam, and medical decision making — all three must meet or exceed the level
For new patients, all three key components (history, physical examination, and medical decision making) must meet or exceed the requirements for the selected level of service.
Under the traditional (pre-2021) E/M guidelines, new patient visits required all three key components at or above the level. Established patients only needed 2 of 3. The 2021 AMA E/M guideline revision changed office visit coding to focus primarily on Medical Decision Making (MDM) or total time, simplifying the documentation burden. However, some specialties and payer contracts still use traditional requirements. Understanding both systems is important for coding accuracy.
Question 2: What is a principal diagnosis in inpatient hospital coding?
- The condition that was present on admission (POA)
- The condition established after study to be chiefly responsible for the admission of the patient to the hospital (Correct answer)
- The most severe diagnosis listed on the claim
- The first diagnosis code entered on the UB-04
Correct answer: The condition established after study to be chiefly responsible for the admission of the patient to the hospital
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.
UHDDS (Uniform Hospital Discharge Data Set) guidelines define the principal diagnosis for inpatient reporting. It may not always be the admitting diagnosis — for example, a patient admitted for chest pain may be diagnosed with GERD after workup; GERD becomes the principal diagnosis. The principal diagnosis drives DRG assignment. Present on Admission (POA) indicators are required for inpatient diagnoses to identify hospital-acquired conditions (HACs). The principal diagnosis is listed in Form Locator 67 on the UB-04.
Question 3: What does the ICD-10-CM Alphabetic Index instruct you to do when you see 'see also'?
- Stop coding and use the suggested main term instead
- Also look up the referenced main term if your current search does not produce a complete code (Correct answer)
- Always use the alternate code provided after the instruction
- Exclude the condition from coding if the additional term applies
Correct answer: Also look up the referenced main term if your current search does not produce a complete code
'See also' in the Alphabetic Index directs the coder to look up an additional main term if the current index entry does not provide complete coding information.
The ICD-10-CM Alphabetic Index uses cross-references: 'See' (mandatory — do not use the current entry, go to the referenced term), 'See also' (advisory — if the entry under the current term is insufficient, also check the referenced term), and 'Code also' (an additional code may be needed). All codes from the Alphabetic Index must be verified in the Tabular List before finalizing. Never code from the index alone.
Question 4: What is the correct coding sequence for a patient admitted for sepsis caused by MRSA pneumonia?
- Code the pneumonia first, then sepsis, then MRSA
- Code the sepsis first (A41.02 Sepsis due to MRSA), then the pneumonia as the underlying infection (Correct answer)
- Code only the MRSA (B95.62) as it is the causal organism
- Code only the sepsis; do not separately code the underlying infection
Correct answer: Code the sepsis first (A41.02 Sepsis due to MRSA), then the pneumonia as the underlying infection
When sepsis and a localized infection (like pneumonia) are present, ICD-10-CM guidelines direct coders to sequence the sepsis code first, followed by a code for the localized infection.
ICD-10-CM Official Guidelines Section I.C.1.d state: if sepsis is the reason for admission and the sepsis is due to a localized infection, the sepsis code is sequenced first. For MRSA sepsis + pneumonia: A41.02 (Sepsis due to MRSA) sequenced first, then J18.9 or the specific pneumonia code (or B95.62 for MRSA as the cause, if instructed by note). Severe sepsis (R65.20) and organ dysfunction codes are added when applicable. Proper sequencing affects DRG assignment and reimbursement.
Question 5: What is the function of CPT Category III codes?
- Codes for supplies and materials beyond those included in service codes
- Temporary codes for emerging technology, services, and procedures used to collect data for FDA approval or coverage decisions (Correct answer)
- Codes for non-physician practitioners performing physician-equivalent services
- Supplemental codes used exclusively for hospital outpatient billing
Correct answer: Temporary codes for emerging technology, services, and procedures used to collect data for FDA approval or coverage decisions
CPT Category III codes (four digits + letter T) are temporary codes for new and experimental services. They are used to collect data and track utilization to support FDA approval or payer coverage decisions.
CPT Category III codes consist of four digits followed by the letter T. They are released semi-annually (January and July). If a Category III code exists for a service, it must be used instead of an unlisted Category I code. Category I codes (the standard numbered CPT codes) are established procedures with proven clinical value. Category II codes are supplemental tracking codes for quality measures. Category III codes sunset after 5 years if not converted to Category I. Payer coverage for Category III codes varies — many are not covered or require prior authorization.
Question 6: When coding a fracture in ICD-10-CM, what information is needed to select the correct 7th character?
- Only the bone that was fractured and the fracture type
- The encounter type (initial, subsequent, sequela), healing status for subsequent encounters, and for open fractures, the Gustilo classification (Correct answer)
- The patient's age and whether surgery was performed
- Only whether the fracture is complete or incomplete
Correct answer: The encounter type (initial, subsequent, sequela), healing status for subsequent encounters, and for open fractures, the Gustilo classification
Fracture coding requires the 7th character to reflect: (1) whether it is an initial encounter (A=closed, B=open type I/II, C=open type IIIA/B/C), (2) subsequent encounter healing status (D=routine, G=delayed, K=nonunion, P=malunion), or (3) sequela (S).
For initial encounters: A = initial encounter for closed fracture, B = initial encounter for open fracture type I or II, C = initial encounter for open fracture type IIIA, IIIB, or IIIC (Gustilo classification). For subsequent encounters: D = routine healing, G = delayed healing, K = nonunion, P = malunion. S = sequela. Pathological fractures and stress fractures have their own 7th character sets. Choosing the wrong 7th character can cause claim denials, particularly for physical therapy and follow-up claims.
CBCS Coding and Coding Guidelines 2
In CPT E/M coding for office visits, which three key components determine the level of service for new patients?