AHIMA CCS Exam Prep with questions and answers

CPT defines a separate procedure as - ans ---Procedure considered an integral part of a more major service No combination code available - ans ---Use separate codes for hypertension and acute renal failure Documentation from the nursing staff or other allied health professionals' notes can be used to provide specificity for code assignment for which of the following diagnoses? - ans ---Body Mass Index (BMI) POA Indicator - Y - ans ---Y-Yes, present at the time of inpatient admission POA Indicator - N - ans ---N-No, not present at the time of inpatient admission POA Indicator - U - ans ---U-Unknown, documentation is insufficient to determine if condition is present on admission and you cannot speak to the physician to figure it out POA Indicator - W - ans ---W-Clinically undetermined, provider is unable to clinically determine whether condition was present on admission or not POA Indicator - E - ans ---E-Exempt, unreported/not used, some facilities will leave these blank, others will use the letter "E" Present on Admission Indicator (POA) - ans ---A Present On Admission (POA) indicator is required on all diagnosis codes for the inpatient setting except for admission. The indicator should be reported for principal diagnosis codes, secondary diagnosis codes, Z-codes, and External cause injury codes. The use of the outpatient code editor (OCE) is designed to: - ans ---Identify incomplete and incorrect claims