Provider Queries Questions for the CCS Exam — Practice Free

Trigger: Completeness/Specificity. Rationale: CHF (I50.9) is a non-specific code. To accurately assign an MS-DRG and capture Severity of Illness (SOI), the coder must query for the type (systolic, diastolic, or combined) and acuity (acute, chronic, or acute on chronic). Clinical indicators like a low Ejection Fraction (EF) suggest systolic dysfunction, but the coder cannot assume. Exam Tip: AHIMA emphasizes that CHF without further specification is a high-frequency query target because specific types (e.g., I50.23) act as CC/MCCs, whereas I50.9 does not.

All multiple-choice queries must include: 1) Clinically significant options supported by the record, 2) Other (please specify), 3) Clinically undetermined, and 4) Not clinically significant. Rationale: Providing these options prevents leading the physician toward a specific high-reimbursement diagnosis. CCS Exam Tip: AHIMA emphasizes that the absence of Other or Undetermined makes a query automatically non-compliant.

A non-leading query must present clinical indicators (Na 125) and ask for a diagnosis without suggesting a specific one. Format: Based on the sodium of 125, please clarify the diagnosis. Avoid: Does the patient have hyponatremia? Multiple-choice is acceptable ONLY if it includes Other, Clinically undetermined, and Not clinically significant. Strategy: AHIMA emphasizes that the provider must arrive at the diagnosis independently based on the clinical evidence presented.

Per AHIMA/ACDIS guidelines and ICD-10-CM Official Guidelines (I.B.14), when there is conflicting documentation between the attending physician and a consultant, the coder must query the attending physician for clarification. Even if clinical indicators (speech therapy, dysphagia) support the consultant’s more specific diagnosis, the coder cannot independently choose the more specific code without a query. STRATEGY: AHIMA emphasizes that the attending has primary responsibility; however, a conflict exists that must be resolved to ensure accurate DRG assignment. Avoid picking the best-supported diagnosis without provider confirmation.

Respiratory distress is not a CC or MCC and does not impact SOI or ROM. Acute Respiratory Failure (J96.00) is a Major Complication or Comorbidity (MCC) and significantly increases both Severity of Illness (SOI) and Risk of Mortality (ROM) levels in the APR-DRG system. Exam Strategy: AHIMA emphasizes that distress is a symptom, while failure is a diagnosis. Without the specific diagnosis, the hospital is under-reimbursed, and the patient's acuity is under-reported. Always look for clinical indicators like BiPAP use and ABG values to support the query.