RHIT - Registered Health Information Technician Medical Coding Principles 2 — Questions and Answers
Question 1: What is the correct definition of the 'principal diagnosis' in inpatient coding?
- The most severe diagnosis
- The condition established after study to be chiefly responsible for occasioning the admission (Correct answer)
- The first diagnosis listed by the physician
- The diagnosis with highest reimbursement
Correct answer: The condition established after study to be chiefly responsible for occasioning the admission
The principal diagnosis is the condition chiefly responsible for the admission, determined after study.
The UHDDS definition drives DRG assignment. Symptoms may be the principal diagnosis if no definitive diagnosis is established. Two conditions may equally meet the definition.
Question 2: In ICD-10-CM, what is the purpose of the seventh character?
- To identify the physician
- To provide additional information such as the type of encounter (initial, subsequent, or sequela) (Correct answer)
- To indicate the patient's age
- To specify the hospital department
Correct answer: To provide additional information such as the type of encounter (initial, subsequent, or sequela)
The seventh character commonly indicates initial (A), subsequent (D), or sequela (S) encounter type.
For injuries it indicates encounter type. For fractures it indicates healing status. For obstetric codes it indicates fetus. A placeholder 'X' maintains the seventh position.
Question 3: What is the difference between a CC and an MCC in the MS-DRG system?
- There is no difference
- An MCC represents a more severe secondary condition with greater impact on resource utilization and higher-weighted DRG (Correct answer)
- A CC is for surgical patients
- CCs apply to Medicare and MCCs to Medicaid
Correct answer: An MCC represents a more severe secondary condition with greater impact on resource utilization and higher-weighted DRG
MCCs represent conditions with higher severity and greater resource consumption impact.
MS-DRGs classify into three tiers: without CC/MCC (lowest weight), with CC (intermediate), and with MCC (highest weight). CMS maintains and annually updates the CC/MCC severity table.
Question 4: When coding an outpatient encounter without a definitive diagnosis, what should the coder assign?
- A 'rule out' diagnosis code
- Signs and symptoms codes that are documented and relevant (Correct answer)
- The most probable diagnosis
- No diagnosis code
Correct answer: Signs and symptoms codes that are documented and relevant
In outpatient settings, uncertain diagnoses are coded using signs and symptoms, not probable or suspected conditions.
Inpatient guidelines allow coding probable/suspected conditions as if confirmed. Outpatient guidelines prohibit this; only confirmed diagnoses may be coded.
Question 5: What is the purpose of CPT modifiers?
- To change the procedure description entirely
- To provide additional information about circumstances without changing the code's definition (Correct answer)
- To increase reimbursement
- To replace the CPT code
Correct answer: To provide additional information about circumstances without changing the code's definition
CPT modifiers indicate that a service was altered by specific circumstances without changing its basic definition.
Common modifiers include -25 (separate E/M), -26 (professional component), -59 (distinct service), -50 (bilateral), -LT/-RT (laterality). Proper modifier use prevents denials.
Question 6: What is unbundling in medical coding and why is it a compliance concern?
- A legitimate coding practice
- Fraudulently billing separately for services that should be reported under a single comprehensive code (Correct answer)
- Removing codes from a claim
- Required for Medicare claims
Correct answer: Fraudulently billing separately for services that should be reported under a single comprehensive code
Unbundling is billing component services separately when a comprehensive code should be used, resulting in inappropriate higher reimbursement.
NCCI edits detect unbundling. Intentional unbundling can result in False Claims Act liability with treble damages, OIG exclusion, and criminal prosecution.
RHIT - Registered Health Information Technician Medical Coding Principles 2
What is the correct definition of the 'principal diagnosis' in inpatient coding?