Free CIC Exam Flashcards

Per UHDDS, the condition established after study to be chiefly responsible for occasioning the admission. It drives MS-DRG assignment and is sequenced first on the claim — not necessarily the most severe condition or the first diagnosis documented.

For inpatient admissions, diagnoses documented as probable, suspected, likely, or still to be ruled out at discharge are coded as if confirmed. Outpatient encounters code only confirmed diagnoses or report signs/symptoms when the diagnosis remains uncertain.

Required for many injury and external-cause codes: A = initial encounter, D = subsequent encounter, S = sequela. Indicates the treatment phase, not visit count. Missing or wrong 7th characters are common CIC coding-case errors.

When a definitive diagnosis is confirmed after workup, code the definitive condition as principal — not the admitting symptom. Example: chest pain (R07.9) is not reported separately when acute STEMI (I21.x) is confirmed as the reason for admission.

When admission purpose is solely to administer chemotherapy, immunotherapy, or external beam radiation, sequence the appropriate Z51 encounter code as principal. Report malignancy codes as secondary diagnoses per neoplasm guidelines.

A condition that develops during the inpatient stay (e.g., post-admission sepsis) is coded as a secondary diagnosis. The admitting condition remains principal unless guidelines specify otherwise. HACs may affect Medicare reimbursement when not present on admission.

Excludes1: codes should never be reported together (mutually exclusive). Excludes2: the excluded condition is not part of the code but may be reported separately if documented. Misreading these notes causes invalid code combinations on CIC cases.

Code also directs reporting an additional code when the condition is present. Code first identifies the etiology or underlying disease that must be sequenced before the manifestation code. Follow chapter-specific sequencing instructions over general rules.

Y = present on admission. N = not present on admission. W = clinically undetermined. U = documentation insufficient to determine POA status. Required on inpatient claims for CMS; drives HAC and quality reporting.

Identifies whether each reported diagnosis existed at inpatient admission order time. CMS uses POA data to distinguish community-acquired conditions from hospital-acquired conditions for payment adjustment and quality measures.

Every PCS code has exactly 7 characters: (1) Section, (2) Body System, (3) Root Operation, (4) Body Part, (5) Approach, (6) Device, (7) Qualifier. Placeholder Z fills positions with no applicable value. No code is shorter or longer than 7 characters.

Excision (B): cutting out a portion of a body part without replacement. Resection (T): cutting out all of a body part. The portion-vs-all distinction is one of the most tested PCS concepts on the CIC exam.

Putting in biological or synthetic material that physically takes the place and/or function of all or a portion of a body part. Used for total joint arthroplasty and similar procedures — not Supplement (which adds to an existing part) or Revision (which corrects a device).

Stopping or attempting to stop postprocedural or other acute bleeding. Coded to the anatomical region, not a specific body part. Distinct from Repair (restore function) and Occlusion (close a lumen completely).

Bypass alters the route of passage through a tubular body part (e.g., CABG). Transfer moves a body part to take over function elsewhere (e.g., tendon transfer). They describe fundamentally different procedural objectives.

Cutting through skin or mucous membrane and any other body layers necessary to expose the operative site. Contrasts with Percutaneous (puncture/minor incision), Percutaneous Endoscopic, and Via Natural or Artificial Opening approaches.

Biopsies map to the root operation describing how tissue is obtained — typically Excision with qualifier Diagnostic (X) for needle biopsies of solid organs. Inspection alone is for visual examination without tissue removal.

Identifies material left in or on the body at procedure end. Z = no device. Synthetic substitutes, autologous tissue substitutes, and other values apply when implants, stents, or grafts remain. Device choice affects DRG surgical classification.

Visually and/or manually exploring a body part without cutting or taking out tissue. Used for diagnostic endoscopy when no other definitive procedure is performed. If a biopsy is taken, code the biopsy root operation instead.

Medicare Severity Diagnosis Related Groups classify inpatient stays into payment groups under IPPS. Each MS-DRG has a relative weight reflecting average resource consumption. Payment = base rate × relative weight (adjusted for hospital-specific factors).

Principal diagnosis, secondary diagnoses (with CC/MCC status), surgical procedures, patient age, sex, and discharge status. The payer identity does not change DRG assignment — coding accuracy drives grouping.

Complication/Comorbidity (CC): moderate impact on resource use. Major CC (MCC): substantially greater impact. Presence of MCCs typically yields higher-paying DRG tiers than CC-only or non-CC cases within the same base DRG family.

Medicare Part A hospital payment system established by 1983 Social Security Amendments (TEFRA). Replaced cost-based reimbursement with prospective DRG-based payment. Most U.S. acute-care hospitals participate.

When a patient is transferred to another acute-care hospital or post-acute setting within the MS-DRG transfer window, payment may be per diem rather than full DRG weight. Coders must report accurate discharge disposition codes.

MS-DRG: Medicare IPPS standard grouper. APR-DRG (All Patient Refined): used by some state Medicaid and all-payer systems; adds severity-of-illness and risk-of-mortality subclasses beyond MS-DRG structure.

Ambulatory Payment Classification groups hospital outpatient services for OPPS payment. Unlike MS-DRG (per stay), APC pays per service/encounter. CIC includes limited outpatient methodology questions for comparison.

A formal request to a provider to clarify ambiguous, conflicting, or incomplete documentation before code assignment. Queries must be non-leading, cite clinical indicators, and follow organizational compliance policies.

Coder must identify: procedure performed, body part(s), approach, extent (partial vs total), devices left in place, and whether diagnostic vs therapeutic. Missing detail often requires a physician query before PCS code assignment.

Summarizes final diagnoses, procedures, hospital course, and discharge disposition. Principal diagnosis selection relies on the final diagnostic statement after study — not the ED admitting diagnosis alone.

EHRs provide simultaneous access to labs, imaging, and progress notes but may contain copy-forward errors. Coders must validate that documented conditions are substantiated in the record, not merely templated.

Services must be reasonable and necessary for diagnosis or treatment. Inpatient admission medical necessity is determined by the admitting physician and supported by documentation. Payers may deny payment if admission level is not justified.

CMS guidance that inpatient admission is generally appropriate when the physician expects the patient to need hospital care crossing two midnights. Shorter stays may still qualify with supporting documentation of medical necessity.

Federal agency administering Medicare, Medicaid, and CHIP. Sets IPPS/OPPS rules, POA reporting, HAC policies, and conditions of participation affecting inpatient coding and reimbursement nationwide.

HHS watchdog investigating healthcare fraud and abuse. Publishes compliance program guidance for hospitals and coders. Up-coding, unbundling, and billing for services not documented are common OIG enforcement targets.

Federal law imposing civil and criminal penalties for knowingly submitting false claims to government programs. Each improper claim can trigger treble damages and per-claim fines. Applies to hospitals and individual coders who knowingly participate.

Internal audits: ongoing quality checks by the facility. External audits: payer or RAC/MAC reviews. Focus areas include DRG validation, PCS accuracy, POA assignment, and principal diagnosis support. Findings drive coder education and compliance plans.

Assigning a higher-paying code or DRG than documentation supports — e.g., reporting a condition as MCC when only a CC is documented. Violates coding ethics and may trigger False Claims Act liability.

Assign codes supported by provider documentation only. Refuse to code unconfirmed diagnoses on outpatient records. Report compliance concerns through proper channels. Never alter records or code for reimbursement impact alone.

When sepsis is present on admission with a localized infection, sequence the underlying infection first per guideline conventions, then A41.x for sepsis, then organ dysfunction codes. POA indicators must reflect timing accurately.

Many codes require right, left, bilateral, or unspecified laterality as part of the code selection. Review operative and imaging documentation for side specificity — unspecified codes are used only when documentation lacks laterality.

Used in certain codes (e.g., poisoning, adverse effects, external causes) to fill a required character position when a 6th or 7th character extension applies but the base code has fewer than six characters before extension.

Correcting a malfunctioning or displaced device or partially replacing a device. Distinct from Replacement (initial device placement) and Removal (taking out without putting in a new device).

Taking or letting out fluids and/or gases from a body part. May include diagnostic qualifier when fluid is sampled. Differs from Extraction (solid matter) and Release (freeing without fluid removal).

Chapter 20 codes describe how injury occurred (mechanism, place, activity, intent). Reported as additional diagnoses on injury claims. Initial encounter requires appropriate 7th character on both injury and external cause codes.

CMS policy reducing IPPS payment when certain conditions (e.g., Stage III/IV pressure ulcers not POA, certain surgical site infections) are coded on the claim. Accurate POA assignment protects appropriate hospital payment.

The procedure most related to the principal diagnosis or performed for definitive treatment. When multiple procedures occur, selection follows UHDDS definitions and coding guidelines — not reimbursement ranking.

Code the histology and site of the malignancy. Secondary neoplasm codes identify metastatic sites. Treatment encounters (surgery, chemo, radiation) have chapter-specific sequencing rules — Z codes may be principal for admission solely for therapy.

Sagittal (left/right division), coronal (front/back), transverse (upper/lower). Proximal/distal, superior/inferior, anterior/posterior appear in operative reports and determine correct body-part characters in PCS codes.

Understanding disease progression (e.g., CHF exacerbation vs chronic stable CHF, acute vs chronic kidney disease stages) helps select specific ICD-10-CM codes and distinguish CC/MCC-eligible conditions from routine comorbidities.

Tab ICD-10-CM and PCS manuals by chapter and common root operations. Practice locating codes under time pressure. Coding cases (65% of score) reward speed and accuracy — multiple-choice knowledge alone is insufficient to pass.