HCC Coding Exam Questions with Correct Answers
What must be clearly listed on each page of a chart? - Answer--Patient name
-2nd Patient Identifier (SSN, DOB, etc.)
-Date of Service
-CMS accepted signature and credential at the end of the note
True or False: Every date of service stands alon...
What must be clearly listed on each page of a chart? - Answer--Patient name
-2nd Patient Identifier (SSN, DOB, etc.)
-Date of Service
-CMS accepted signature and credential at the end of the note
True or False: Every date of service stands alone. - Answer-True.
If a diagnosis is noted on a January visit and a February visit, but not on a July visit, can
the diagnosis still be coded on the July visit? - Answer-No.
What constitutes an acceptable encounter? - Answer-It must include a face-to-face visit
with a CMS acceptable provider.
What does not constitute a face-to-face visit? - Answer--MRI
-X-ray
-Radiology
True or False: A pathology report counts as a face-to-face encounter. - Answer-True.
Why can't coders code from labs? - Answer-The doctor must be the one to interpret the
lab findings.
What two sections of the medical record can you almost always code from? - Answer--
Exam section
-Assessment (Plan) section
What section of the medical record is considered the "Gold Standard" of documentation
in HCC coding? - Answer-The exam section.
Do coders typically code from the chief complaint section? - Answer-No. This is typically
documentation from the patient's point of view about the medical problem.
Do coders typically code from the History of Present Illness (HPI) section? - Answer-No.
This section often uses "history of". It is often just the patient's summary of the reason
for the visit.
Do coders typically code from the Review of Systems (ROS) section? - Answer-No. This
section is often completed by the patient in the waiting room.
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