Certified Medical Coding Specialist Quality Control & Assurance 5 — Questions and Answers
Question 1: Which of the following is an example of a 'never event' as defined by CMS that affects hospital reimbursement?
- Readmission within 30 days for COPD
- Wrong-site surgery (Correct answer)
- Extended length of stay for pneumonia
- Elective admission for joint replacement
Correct answer: Wrong-site surgery
Wrong-site surgery is classified as a 'never event' or serious reportable event; CMS does not reimburse for the additional costs of treating conditions that result from these events.
Question 2: In a coding quality program, 'interrater reliability' refers to:
- The consistency of a single coder's results over time
- The degree of agreement between two or more coders coding the same record (Correct answer)
- The accuracy of codes compared to payer guidelines
- The match rate between codes and clinical documentation
Correct answer: The degree of agreement between two or more coders coding the same record
Interrater reliability measures how consistently different coders assign the same codes to the same records, indicating standardization of coding practices.
Question 3: A hospital implements a computer-assisted coding (CAC) system. Quality assurance for CAC-generated codes should include:
- Eliminating human review since CAC is automated
- Coder review and validation of all CAC-suggested codes before submission (Correct answer)
- Using CAC codes only for outpatient encounters
- Applying CAC suggestions without modification to improve speed
Correct answer: Coder review and validation of all CAC-suggested codes before submission
CAC systems require human review and validation because they can suggest incorrect codes; coders must verify clinical accuracy before claim submission.
Question 4: The 'two-midnight rule' affects inpatient admission quality reviews by establishing that:
- All admissions lasting less than two nights must be coded as outpatient
- CMS generally expects inpatient admission to be appropriate when a physician reasonably expects a stay spanning at least two midnights (Correct answer)
- Patients admitted after midnight always qualify for inpatient status
- Two-midnight stays are automatically covered under observation status
Correct answer: CMS generally expects inpatient admission to be appropriate when a physician reasonably expects a stay spanning at least two midnights
The two-midnight rule states that CMS considers inpatient admission appropriate when the physician reasonably expects the patient to need hospital care spanning two midnights.
Question 5: Which action would BEST demonstrate that a coding department's quality improvement plan is working?
- Increasing the number of codes assigned per chart
- A statistically significant reduction in error rate from one audit cycle to the next (Correct answer)
- Decreasing the average time to code a record
- Expanding the number of coders employed
Correct answer: A statistically significant reduction in error rate from one audit cycle to the next
A measurable, statistically significant reduction in error rate between audit cycles is the strongest evidence of effective quality improvement.
Question 6: Under the Stark Law, which of the following financial relationships between a physician and an entity is PROHIBITED (unless an exception applies)?
- A physician referring Medicare patients to a hospital where they have an ownership interest (Correct answer)
- A physician purchasing medical supplies at fair market value
- A physician accepting speaking honoraria below the nominal value threshold
- A physician receiving a productivity bonus based on personally performed services
Correct answer: A physician referring Medicare patients to a hospital where they have an ownership interest
Stark Law prohibits physician self-referrals to entities where the physician has a financial relationship for designated health services billed to Medicare, unless a specific exception applies.
Question 7: A coder notices that a physician's documentation includes a diagnosis not supported by any clinical indicators in the record. The CORRECT action is to:
- Code the diagnosis as documented since physician attestation is sufficient
- Query the physician to clarify the clinical basis for the diagnosis before coding it (Correct answer)
- Omit the diagnosis and code only documented signs and symptoms
- Report the physician to the compliance officer immediately
Correct answer: Query the physician to clarify the clinical basis for the diagnosis before coding it
When documentation appears inconsistent with clinical indicators, the coder should query the physician for clarification rather than coding an unsupported diagnosis or omitting it without verification.
Certified Medical Coding Specialist Quality Control & Assurance 5
Which of the following is an example of a 'never event' as defined by CMS that affects hospital reimbursement?