Certified Medical Coding Specialist Professional Standards & Competencies 4 — Questions and Answers
Question 1: A coder is uncertain whether a condition documented as 'possible pneumonia' should be coded for an outpatient encounter. The correct approach is to:
- Code the confirmed diagnosis of pneumonia
- Code the sign or symptom prompting the evaluation, not the uncertain condition (Correct answer)
- Query the physician to confirm the diagnosis before the visit closes
- Leave the diagnosis field blank
Correct answer: Code the sign or symptom prompting the evaluation, not the uncertain condition
Outpatient coding guidelines prohibit coding uncertain diagnoses; the coder reports the sign or symptom instead.
Question 2: Which of the following practices could constitute Medicare fraud?
- Billing for a 99213 when a 99212 was documented (Correct answer)
- Applying correct modifiers to distinguish bilateral procedures
- Using late charges to correct a billing error within the timely filing period
- Querying a physician for additional diagnosis documentation
Correct answer: Billing for a 99213 when a 99212 was documented
Billing a higher-level E/M service than the documentation supports is upcoding, which constitutes Medicare fraud.
Question 3: Continuing education units (CEUs) are required for CMCS credential maintenance primarily to ensure:
- Coders earn higher salaries over time
- Knowledge stays current with evolving coding systems and regulations (Correct answer)
- Coders meet state licensing requirements
- Billing software remains up to date
Correct answer: Knowledge stays current with evolving coding systems and regulations
CEUs keep credentialed professionals current with changing codes, guidelines, and regulations that affect coding accuracy.
Question 4: Which of the following is the best example of a 'query' in the coding context?
- A coder corrects a physician's note to clarify a diagnosis
- A coder sends a written request asking the physician to clarify if a condition is related to a procedure (Correct answer)
- A coder reports a physician's documentation pattern to the compliance officer
- A coder calls the insurance company to clarify coverage
Correct answer: A coder sends a written request asking the physician to clarify if a condition is related to a procedure
A compliant query is a written communication asking the provider to clarify documentation without leading to a specific answer.
Question 5: The concept of 'code linkage' in medical billing refers to:
- Linking two ICD codes from the same code family
- Connecting the diagnosis code to the procedure code to demonstrate medical necessity (Correct answer)
- Pairing a CPT code with an HCPCS modifier
- Assigning the same code to related visits within one episode of care
Correct answer: Connecting the diagnosis code to the procedure code to demonstrate medical necessity
Code linkage connects the diagnosis to the procedure on the claim to demonstrate that the service was medically necessary.
Question 6: Which scenario best illustrates 'unbundling' in medical coding?
- Billing a global surgical package for a routine procedure
- Separately billing components of a procedure that should be reported as a single comprehensive code (Correct answer)
- Using modifier -59 when services are truly distinct
- Reporting an E/M service on the same day as a procedure with modifier -25
Correct answer: Separately billing components of a procedure that should be reported as a single comprehensive code
Unbundling is billing individual components of a procedure separately when a single comprehensive code exists, which is improper billing.
Question 7: A coder who belongs to a professional coding organization is expected to adhere to that organization's code of ethics primarily because:
- Ethics violations result in automatic criminal charges
- Ethical practice upholds accuracy, integrity, and public trust in the profession (Correct answer)
- Ethics compliance is required by OSHA
- Following the code of ethics guarantees claim payment
Correct answer: Ethical practice upholds accuracy, integrity, and public trust in the profession
Professional codes of ethics exist to maintain integrity, accuracy, and public confidence in medical coding and health information.
Certified Medical Coding Specialist Professional Standards & Competencies 4
A coder is uncertain whether a condition documented as 'possible pneumonia' should be coded for an outpatient encounter.
The correct approach is to: