Domain 1: Coding Knowledge and Skills - Sample Questions

Task 1: Assign diagnosis and procedure codes based on the provider’s documentation in the health record

Question - A 63-year-old patient undergoes a laparoscopic cholecystectomy. Assign the appropriate procedure code.

Task 2: Identify principal/first-listed diagnosis and procedure based on the respective guidelines

Question - In a hospital admission due to sepsis secondary to pneumonia, what should be coded as the principal diagnosis?

Task 3: Apply coding conventions/guidelines and regulatory guidance

Question - When documenting multiple fractures, what coding convention must be followed according to ICD-10-CM?

Task 4: Attach CPT/HCPCS modifiers to outpatient procedures

Question - Which modifier is appropriate when the same procedure is performed on both left and right sides during the same operative session?

Task 5: Determine appropriate sequencing of diagnoses and procedure codes based on the case scenario

Question - How should the diagnoses be sequenced for a patient admitted for chest pain who is later diagnosed with myocardial infarction?

Task 6: Apply present on admission (POA) guidelines

Question - How is a decubitus ulcer documented on admission handled for POA indicator assignment?

Task 7: Demonstrate knowledge of coding edits (e.g., NCCI, Medical Necessity)

Question - Which tool helps coders determine whether two procedures can be reported together based on bundling rules?

Task 8: Demonstrate knowledge of reimbursement methodologies (e.g., DRG, APC)

Question - What is the purpose of the MS-DRG system in inpatient hospital reimbursement?

Task 9: Abstract applicable data from the health record

Question - What type of information must be abstracted for outpatient surgical procedures?

Task 10: Identify major co-morbid conditions (MCC) and co-morbid conditions (CC)

Question - Which of the following diagnoses is considered an MCC under MS-DRG grouping rules?

Domain 2: Coding Documentation - Sample Questions

Task 1: Resolve conflicting documentation in the health record

Question - If one provider documents "fractured left femur" and another documents "right femur," how should the coder proceed?

Task 2: Ensure all required documentation for assigning a specified code is available within the health record

Question - Before coding a colonoscopy with polypectomy, what documentation should be confirmed in the operative report?

Task 3: Verify and validate documentation within the health record

Question - How should a coder respond when a diagnosis lacks supporting clinical documentation?

Domain 3: Provider Queries - Sample Questions

Task 1: Identify elements of an ethical compliant query

Question - What is one essential component that ensures a provider query is compliant and ethical?

Task 2: Determine if a provider query is compliant

Question - Which of the following is an example of a compliant, non-leading query regarding anemia?

Task 3: Analyze current documentation to identify query opportunities

Question - What scenario would warrant a query to clarify heart failure type in a patient record?

Domain 4: Regulatory Compliance - Sample Questions

Task 1: Ensure completeness and accuracy of health records

Question - Which process verifies that a patient’s discharge summary aligns with coded diagnoses?

Task 2: Understand payer-specific guidelines

Question - What guideline must be followed when assigning codes for Medicare patients with outpatient services?

Task 3: Identify patient safety indicators (PSIs) and hospital-acquired conditions (HACs)

Question - Which condition qualifies as a hospital-acquired condition under CMS guidelines?

Task 4: Ensure compliance with HIPAA guidelines

Question - What action is a potential violation of HIPAA privacy regulations by a medical coder?

Task 5: Ensure adherence to AHIMA Standards of Ethical Coding

Question - According to AHIMA’s ethical standards, what must a coder do when a supervisor instructs to “upcode” for reimbursement?

Task 6: Ensure compliance with the Uniform Hospital Discharge Data Set (UHDDS)

Question - What is the significance of UHDDS in selecting a principal diagnosis?

Domain 5: Information Technologies - Sample Questions

Task 1: Distinguish various types of Electronic Health Records (EHR)

Question - What is one key difference between integrated EHRs and stand-alone systems?

Task 2: Demonstrate a basic understanding of encoding and grouper software

Question - What is the purpose of a grouper software in inpatient hospital coding?

Task 3: Exhibit an understanding of computer-assisted coding (CAC) software and its impact on coding

Question - What is a potential risk when relying solely on CAC software for code assignment?

Task 4: Ensure compliance with HITECH guidelines

Question - What requirement under HITECH affects how coders handle patient data breaches?