CCS Exam Preparation, Domain 4:
Regulatory Compliance
After consulting with a physician, a coding supervisor has issued an internal policy stating that
all bedside debridement be coded as excisional. Is this an ethical practice for a coding
professional to follow? Why or why not?
A. Yes, physician guidance provided basis for the policy.
B. Yes, coding professionals must follow internal policies of the facilities where they are
employed.
C. No, coding supervisors cannot make internal policies without approval of administration.
D. No, internal policies cannot conflict with requirements provided in coding guidelines,
conventions, and so on. - ANSD. No, internal policies cannot conflict with requirements provided
in coding guidelines, conventions, and so on.
Ethical Coding Guideline 1.2 states that internal policies may not conflict with the coding rules,
conventions, guidelines, etc. of the coding classifications nor with any official coding advice
(AHIMA House of Delegates 2016).
The coding supervisor is concerned that patients diagnosed with carcinoid colon tumors were
miscoded as malignant during the last six months. To address this situation, what work
processes could be undertaken?
A. Obtain the cases of carcinoid colon tumors from the cancer registry, obtain the cases of
malignant colon tumors from the billing system, import both lists into a spreadsheet, and
compare them. The cases in the cancer registry but not coded as carcinoid in the billing system
are likely malignant and should be manually reviewed.
B. Compare the cases from the chart completion software with the billing software. Identify the
cases that are not in the billing system. These cases should be manually reviewed to ensure
they are not carcinoid tumors.
C. Obtain the cases of malignant colon tumors from both the cancer registry and the billing
system; import both lists into a spreadsheet and compare them. Identify - ANSC. Obtain the
cases of malignant colon tumors from both the cancer registry and the billing system; import
both lists into a spreadsheet and compare them. Identify the cases that are not in the tumor
,registry but are coded as malignant in the billing system. These cases should be manually
reviewed to ensure they are not carcinoid tumors.
The diagnostic index can be used with the cancer registry data to undertake data quality
analysis (Johns 2020, 85).
The patient was admitted for prostate carcinoma. This was treated with radiation. A member of
the medical staff who was not associated with the patient's care requests to see the patient's
health record. What should the coding professional do?
A. Provide the record to the physician.
B. Report the incident to hospital security.
C. Ask the physician to come back when the supervisor gets back.
D. Explain that providing the record would violate the privacy policy - ANSD. Explain that
providing the record would violate the privacy policy
This question relates to the need-to-know principle. The medical staff member who is not
associated with the patient's care does not need to see that patient's record (Hamilton 2020,
669-670).
Under which of the following circumstances does a healthcare entity lose a potential increase in
reimbursement when a hospital-acquired condition (HAC) is coded without a POA indicator of
"Y"?
A. When the HAC is the only CC/MCC on the account
B. When the HAC is listed as the principal diagnosis
C. When the HAC is coded along with a surgical procedure
D. When the HAC is the only diagnosis listed - ANSA. When the HAC is the only CC/MCC on
the account
It is only in the circumstance when the HAC is the only CC/MCC on the patient's account, and
does not carry a POA indicator of Y, will there be a loss of an opportunity to capture additional
reimbursement (Casto and White 2021, 85).
To correct an entry in a paper-based medical record, the provider should:
A. Draw a single line through the error, add a note explaining the error, initial and date, add the
correct information in chronological order
B. Draw a double line through the error, initial and date, add the reason for the correction
C. Draw a single line through the error, and add the correct information in chronological order
D. Draw several lines through the error, obliterate the documentation as much as possible, initial
and date, add the correct information in chronological order - ANSA. Draw a single line through
the error, add a note explaining the error, initial and date, add the correct information in
chronological order
, If an error is corrected, the healthcare provider who made the error should draw a single line
through the error, add a note explaining the error, initial and date it, and add the correct
information in chronological order (Sayles 2020, 78). Further, AHIMA principles for health record
documentation specify the prior statement as the proper method for correcting an error in the
paper-based records in order to maintain a legally sound record. This process is based on the
ASTM and HL7 standards for error correction (AHIMA e-HIM Work Group on Maintaining the
Legal EHR 2005).
Most hospitals require a medical record to be completed within:
A. 5 days
B. 10 days
C. 7 days
D. 30 days - ANSD. 30 days
The Medicare Conditions of Participation and the Joint Commission require that the medical
record is completed no later than 30 days following discharge of the patient (Brickner 2020, 97).
What is the term used when protected health information has been disclosed inappropriately?
A. Exposure
B. Breach
C. Violation
D. Infraction - ANSB. Breach
Under HITECH, when there has been unauthorized access or disclosure of protected health
information, a breach is found to have occurred (Rinehart-Thompson 2017b, 250-251).
The minimum necessary requirement would apply in which of the following scenarios?
A. When disclosure is to the secretary of HHS for investigation
B. When disclosure is required by law
C. When disclosure is for payment
D. When disclosure is made to the personal representative of the individual - ANSC. When
disclosure is for payment
Disclosures made for payment fall under the minimum necessary doctrine, while in the other
circumstances listed, the minimum necessary standard does not apply (Rinehart-Thompson
2017a, 232-233).
According to the UHDDS, section III, the definition of other diagnoses is all conditions that:
A. Coexist at the time of admission, that develop subsequently, or that affect the treatment
received or the length of stay.
B. Receive evaluation and are documented by the physician
C. Receive clinical evaluation, therapeutic treatment, further evaluation, extend the length of
stay, increase nursing monitoring/care
Regulatory Compliance
After consulting with a physician, a coding supervisor has issued an internal policy stating that
all bedside debridement be coded as excisional. Is this an ethical practice for a coding
professional to follow? Why or why not?
A. Yes, physician guidance provided basis for the policy.
B. Yes, coding professionals must follow internal policies of the facilities where they are
employed.
C. No, coding supervisors cannot make internal policies without approval of administration.
D. No, internal policies cannot conflict with requirements provided in coding guidelines,
conventions, and so on. - ANSD. No, internal policies cannot conflict with requirements provided
in coding guidelines, conventions, and so on.
Ethical Coding Guideline 1.2 states that internal policies may not conflict with the coding rules,
conventions, guidelines, etc. of the coding classifications nor with any official coding advice
(AHIMA House of Delegates 2016).
The coding supervisor is concerned that patients diagnosed with carcinoid colon tumors were
miscoded as malignant during the last six months. To address this situation, what work
processes could be undertaken?
A. Obtain the cases of carcinoid colon tumors from the cancer registry, obtain the cases of
malignant colon tumors from the billing system, import both lists into a spreadsheet, and
compare them. The cases in the cancer registry but not coded as carcinoid in the billing system
are likely malignant and should be manually reviewed.
B. Compare the cases from the chart completion software with the billing software. Identify the
cases that are not in the billing system. These cases should be manually reviewed to ensure
they are not carcinoid tumors.
C. Obtain the cases of malignant colon tumors from both the cancer registry and the billing
system; import both lists into a spreadsheet and compare them. Identify - ANSC. Obtain the
cases of malignant colon tumors from both the cancer registry and the billing system; import
both lists into a spreadsheet and compare them. Identify the cases that are not in the tumor
,registry but are coded as malignant in the billing system. These cases should be manually
reviewed to ensure they are not carcinoid tumors.
The diagnostic index can be used with the cancer registry data to undertake data quality
analysis (Johns 2020, 85).
The patient was admitted for prostate carcinoma. This was treated with radiation. A member of
the medical staff who was not associated with the patient's care requests to see the patient's
health record. What should the coding professional do?
A. Provide the record to the physician.
B. Report the incident to hospital security.
C. Ask the physician to come back when the supervisor gets back.
D. Explain that providing the record would violate the privacy policy - ANSD. Explain that
providing the record would violate the privacy policy
This question relates to the need-to-know principle. The medical staff member who is not
associated with the patient's care does not need to see that patient's record (Hamilton 2020,
669-670).
Under which of the following circumstances does a healthcare entity lose a potential increase in
reimbursement when a hospital-acquired condition (HAC) is coded without a POA indicator of
"Y"?
A. When the HAC is the only CC/MCC on the account
B. When the HAC is listed as the principal diagnosis
C. When the HAC is coded along with a surgical procedure
D. When the HAC is the only diagnosis listed - ANSA. When the HAC is the only CC/MCC on
the account
It is only in the circumstance when the HAC is the only CC/MCC on the patient's account, and
does not carry a POA indicator of Y, will there be a loss of an opportunity to capture additional
reimbursement (Casto and White 2021, 85).
To correct an entry in a paper-based medical record, the provider should:
A. Draw a single line through the error, add a note explaining the error, initial and date, add the
correct information in chronological order
B. Draw a double line through the error, initial and date, add the reason for the correction
C. Draw a single line through the error, and add the correct information in chronological order
D. Draw several lines through the error, obliterate the documentation as much as possible, initial
and date, add the correct information in chronological order - ANSA. Draw a single line through
the error, add a note explaining the error, initial and date, add the correct information in
chronological order
, If an error is corrected, the healthcare provider who made the error should draw a single line
through the error, add a note explaining the error, initial and date it, and add the correct
information in chronological order (Sayles 2020, 78). Further, AHIMA principles for health record
documentation specify the prior statement as the proper method for correcting an error in the
paper-based records in order to maintain a legally sound record. This process is based on the
ASTM and HL7 standards for error correction (AHIMA e-HIM Work Group on Maintaining the
Legal EHR 2005).
Most hospitals require a medical record to be completed within:
A. 5 days
B. 10 days
C. 7 days
D. 30 days - ANSD. 30 days
The Medicare Conditions of Participation and the Joint Commission require that the medical
record is completed no later than 30 days following discharge of the patient (Brickner 2020, 97).
What is the term used when protected health information has been disclosed inappropriately?
A. Exposure
B. Breach
C. Violation
D. Infraction - ANSB. Breach
Under HITECH, when there has been unauthorized access or disclosure of protected health
information, a breach is found to have occurred (Rinehart-Thompson 2017b, 250-251).
The minimum necessary requirement would apply in which of the following scenarios?
A. When disclosure is to the secretary of HHS for investigation
B. When disclosure is required by law
C. When disclosure is for payment
D. When disclosure is made to the personal representative of the individual - ANSC. When
disclosure is for payment
Disclosures made for payment fall under the minimum necessary doctrine, while in the other
circumstances listed, the minimum necessary standard does not apply (Rinehart-Thompson
2017a, 232-233).
According to the UHDDS, section III, the definition of other diagnoses is all conditions that:
A. Coexist at the time of admission, that develop subsequently, or that affect the treatment
received or the length of stay.
B. Receive evaluation and are documented by the physician
C. Receive clinical evaluation, therapeutic treatment, further evaluation, extend the length of
stay, increase nursing monitoring/care
