Click here for more sample CPC practice exam questions with Full Rationale Answers

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Click here for more sample CPC practice exam questions and answers with full rationale

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What makes a good CPC Practice Exam? Questions and Answers with Full Rationale

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Practice Exam

2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers

Practice Exam

Click here for more sample CPC practice exam questions and answers with full rationale

Advice From a CFPC™

AAPC member Kolene McGrath, RN, MSN, CPC, CFPC, works at a small family practice in a rural community. As a registered nurse with a Master of Science in Nursing, McGrath combines clinical knowledge with her coding certifications — a great benefit to patients and staff alike. McGrath works directly with several insurance companies regarding quality […]

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AAPC Knowledge Center

Advice From a CEMC™

AAPC member Meenu Agarwal, CPC, CRC, CEMC, CPCD, CPEDC, has five and a half years of work experience in medical coding and auditing and currently works as a medical coder in Portland, Oregon. AAPC asked Agarwal about her experience with earning the Certified Evaluation and Management Coder (CEMC™) credential and how it has helped her […]

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AAPC Knowledge Center

Advice From a CHONC™

AAPC member Emily Williams, CPC, COC, CPMA, CHONC, has been coding for 10 years. She is currently a coder at a large multispecialty group and has experience coding oncology/hematology, gastroenterology (GI), anesthesia, pain management, radiology, dermatology, and cardiology. AAPC asked Williams about her experience with earning the Certified Hematology and Oncology Coder (CHONC™) credential and […]

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AAPC Knowledge Center

Advice From a CPEDC™

AAPC member Astara N. Crews, MJ, CHC, CHPC, CHIAP, CPC, CPEDC, has worked in healthcare for 25 years and is currently a senior compliance officer and HIPAA privacy and security officer for a mid-size healthcare system in New York state’s Mid-Hudson Valley and Western Connecticut regions. AAPC asked Crews about her experience with earning the […]

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AAPC Knowledge Center

Advice From a CCVTC™

AAPC member Lena Holbrook, CPC, CDEO, CPMA, CCVTC, CEMC, has worked in healthcare for 15 years and currently works for a revenue cycle management company. AAPC asked Holbrook about her experience with earning the Certified Cardiovascular and Thoracic Surgery Coder (CCVTC™) credential and how it has helped her career. What led you to obtain the […]

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AAPC Knowledge Center

Advice From a CIRCC®

AAPC member Patricia Sonnemann, CPC, COC, CIC, CIRCC, CPMA, works for Concept Plus LLC, where she audits medical records for correct coding for Tricare members. Sonnemann has been in the industry for over 30 years, and she earned her first certified medical coding credential in 2002. AAPC asked Sonnemann about her experience with earning the Certified […]

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AAPC Knowledge Center

Possible Repercussions from SNF 2022 Proposed Rule

The 2022 proposed rule for SNFs is out, and few stakeholders are surprised at the meat of the rule. The fiscal year (FY) 2022 proposed rule affects Medicare payment policies and rates under the skilled nursing facility (SNF) prospective payment system, but also includes proposals for the quality reporting program and the SNF value-based program. […]

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AAPC Knowledge Center

Advice From a CHONC™

AAPC member Donna Stanhope, CPC, CHONC, is a 20-year veteran in the healthcare system. She has worked as a financial review specialist at a large oncology practice in Maine for the last four years, where she started as an insurance verification specialist. AAPC asked Stanhope about her experience with earning the Certified Hematology and Oncology […]

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AAPC Knowledge Center

Q&A: Coding from ED documentation and test results

Q: Can you code strictly from emergency department (ED) documentation? Can you code from test results and imaging (radiologist reports)?
 
A: Coders can assign diagnosis codes based on documentation of any licensed independent provider that provides direct care to the patient. This includes physicians, nurse practitioners, and physician assistants who provide care to the patient during this encounter. Thus, the documentation of ED physicians or other providers (nurse practitioners and physician assistants) can be used to assign a code.
 
This comes with two notes of caution, however. First, this documentation must not conflict with the attending physician. If the documentation conflicts, then query for clarification. Second, if the ED physician documents a diagnosis, but you see no evidence of treatment or monitoring continued through the inpatient stay, query for the significance of the diagnosis.
 
As for the second piece of your question, diagnosis codes cannot be assigned based on test results or imaging. The documentation of radiologists and pathologists cannot be used to assign diagnosis codes, as such physicians do not provide direct patient care. Coders or clinical documentation improvement (CDI) specialists would need to query the attending provider to assign the appropriate diagnosis code.
 
Coding Clinic for ICD-10-CM/PCS has published guidance regarding the use of such reports to further specify the location of a fracture or cerebrovascular accident from imaging. But we first must have the diagnosis as documented by the attending physician or provider responsible for the direct care of the patient.
 
Editor’s note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, and CDI education specialist at HCPro, a division of BLR, in Danvers, Massachusetts, answered this question on the ACDIS website. Contact her at [email protected].
 
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

 

Need expert coding advice? Submit your question to editor Steven Andrews at [email protected] and we’ll do our best to get an answer for you.

HCPro.com – JustCoding News: Inpatient