22 Coding Compliance & Queries Practice Questions & Answers

1. 1. A record documents a hemoglobin of 7.9 g/dL, two units of packed cells transfused on 3/4, and no related diagnosis. Which query wording meets compliant query standards?

   • A.Hgb 7.9 g/dL with 2 units of packed cells given; please document acute blood loss anemia here.
   • B.Hgb 7.9 g/dL on 3/4; 2 units of packed cells given 3/4. Please clarify the significance.✓ Answer
   • C.The patient clearly meets anemia criteria, so please add anemia to the discharge summary.
   • D.Hgb 7.9 g/dL with transfusion; documenting anemia supports a higher-weighted DRG here.

   A compliant query presents only the clinical indicators actually documented, with their dates, and asks the provider to interpret them; it does not supply the querying professional's own interpretation. Naming the diagnosis for the provider to rubber-stamp, asserting that clinical criteria are met, or attaching payment impact all steer the answer and make the query leading.

   Source: AHIMA/ACDIS, Guidelines for Achieving a Compliant Query Practice (2022 Update) — non-leading query constructionReport a problem with this question

2. 2. A query sent to a physician ends with: "Answering this query will move the encounter to a higher-weighted MS-DRG." Under the 2022 compliant query guidelines, the query is:

   • A.Non-compliant only because a CDI specialist rather than a coding professional sent it.
   • B.Acceptable, as long as the statement is placed after the answer choices, not before them.
   • C.Acceptable, since the provider is entitled to know how the documentation affects payment.
   • D.Non-compliant, because a query must never state or imply the impact on reimbursement or a DRG.✓ Answer

   The compliant query standards bar any reference to reimbursement, DRG weight, quality measures, or other reportable impact anywhere in the query, including its title, because such a statement gives the provider a reason to answer other than the clinical truth. Position within the document and the credential of the sender do not cure the defect; any query professional may query, and the content itself is what makes this one leading.

   Source: AHIMA/ACDIS, Guidelines for Achieving a Compliant Query Practice (2022 Update) — leading query prohibitionsReport a problem with this question

3. 3. Under the 2022 guidelines, a yes/no query format is appropriate in which situation?

   • A.Obtaining a new diagnosis that no provider has documented in the encounter.
   • B.Prompting the provider to choose among undocumented conditions the coder suspects.
   • C.Replacing an open-ended query whenever the coder already knows the desired answer.
   • D.Establishing whether a documented condition was present on admission.✓ Answer

   Yes/no queries are limited to a short closed list of purposes: further specifying an already-documented diagnosis, determining present-on-admission status, substantiating a diagnosis already in the record through a provider-interpreted finding, and establishing or negating cause-and-effect or resolving conflicting documentation. Using the format to obtain a diagnosis that appears nowhere in the record introduces new information and is per se leading.

   Source: AHIMA/ACDIS, Guidelines for Achieving a Compliant Query Practice (2022 Update) — yes/no query formatReport a problem with this question

4. 4. A coder builds a multiple-choice query. Which construction meets the compliant query standards?

   • A.Include only options supported by the cited indicators, plus "other, please specify".✓ Answer
   • B.Bold the option the clinical indicators most strongly support so it is easy to see.
   • C.List every diagnosis in the differential, including ones the record does not support.
   • D.Offer exactly three clinical options, since fewer than three is considered leading.

   The guidelines require that every listed choice be clinically plausible and traceable to indicators reproduced in the query itself, and that a free-text "other, please specify" option always be available so the provider is never boxed in. There is no required minimum or maximum number of options, and typographic emphasis such as bolding or highlighting is expressly treated as steering the provider.

   Source: AHIMA/ACDIS, Guidelines for Achieving a Compliant Query Practice (2022 Update) — multiple-choice query formatReport a problem with this question

5. 5. A physician answers a query "cannot be determined." The coder is told to send the same query to another physician on the case, hoping for a more specific answer. This is:

   • A.Appropriate, because any provider treating the patient during the stay may answer.
   • B.Non-compliant, because re-querying to obtain a desired answer is prohibited practice.✓ Answer
   • C.Non-compliant only when the second query is verbal rather than written and tracked.
   • D.Appropriate, because the first response added no clarification to the record.

   Sending the same query again, to the same provider or a different one, in order to get a more favorable answer is explicitly non-compliant, and the same rule bars following a technology-generated query with a manual one on the same condition when no new clinical indicators have appeared. A second query is defensible only when new documentation or new clinical information has entered the record.

   Source: AHIMA/ACDIS, Guidelines for Achieving a Compliant Query Practice (2022 Update) — repeat queriesReport a problem with this question

6. 6. The record documents "community-acquired pneumonia" with no organism identified and no clinical clue pointing to one. A valid code exists. What should the coder do?

   • A.Hold the chart unbilled until the provider adds an organism to the discharge summary.
   • B.Assign the organism suggested by the sputum culture result in the laboratory report.
   • C.Query the provider for a causal organism so the most specific code available can be used.
   • D.Assign the code the documentation supports; no query is warranted on these facts.✓ Answer

   The 2022 guidelines state that code accuracy is not the same as code specificity: when the documentation supports a valid code and nothing in the record indicates that a more specific diagnosis exists, there is no business need for a query and sending one only adds query fatigue. A coder also may not assign an organism from a laboratory result on the coder's own reading, because the diagnosis must come from the provider.

   Source: AHIMA/ACDIS Compliant Query Practice (2022 Update) — when not to query; ICD-10-CM Guidelines I.B.14Report a problem with this question

7. 7. The attending documents "CVA," the neurology consultant documents "TIA," and the discharge summary says "cerebrovascular event." What is the appropriate action?

   • A.Sequence both conditions and let the grouper pick which one comes first.
   • B.Query the attending physician to resolve the conflicting documentation.✓ Answer
   • C.Assign the attending's diagnosis, because the attending outranks the consultant.
   • D.Report the least specific of the three terms, since the record does not agree.

   Conflicting documentation among providers is one of the classic triggers for a query, and the guidelines direct that the conflict be taken to the attending physician, who is responsible for the overall care and for reconciling the record. Choosing one provider's term by seniority, defaulting to the vaguest term, or reporting both conditions all resolve the conflict by coder assumption instead of by provider statement.

   Source: AHIMA/ACDIS Compliant Query Practice (2022 Update) — conflicting documentation; query the attendingReport a problem with this question

8. 8. A provider documents "acute respiratory failure," but the coder finds no supporting values in the record. Per ICD-10-CM Guideline I.A.19 and compliant query practice, the coder should:

   • A.Send a clinical validation query citing the record findings and options.✓ Answer
   • B.Delete the diagnosis, because the clinical indicators do not support the code.
   • C.Refer the record to the physician advisor to supply the correct final diagnosis.
   • D.Assign the code as documented, because coders may never question a provider.

   Guideline I.A.19 says code assignment rests on the provider's diagnostic statement rather than on whether the coder believes clinical criteria were met, so a coder may not unilaterally strike a documented diagnosis. When the documentation appears clinically unsupported, the compliant remedy is a clinical validation query that lays out the findings and lets the provider confirm, rule out, or offer another explanation; the physician advisor may facilitate but does not answer in the treating provider's place.

   Source: ICD-10-CM Official Guidelines I.A.19; AHIMA/ACDIS Compliant Query Practice (2022 Update) — clinical validationReport a problem with this question

9. 9. A registered dietitian documents a BMI of 41.2; the physician documents "obesity" but no BMI. Which statement is correct?

   • A.The BMI may be coded from the dietitian's note as a secondary code, with obesity from the provider.✓ Answer
   • B.Neither the BMI nor the obesity may be coded until the physician restates the value.
   • C.The BMI may be coded, and the coder may add morbid obesity based on that BMI value alone.
   • D.The BMI may be coded as the first-listed diagnosis when the provider has not stated one.

   Guideline I.B.14 lists a closed set of items that may be taken from a clinician who is not the patient's provider, and body mass index is one of them, but the associated diagnosis such as obesity must still be documented by the provider. BMI is reportable only as a secondary code and never as a principal or first-listed diagnosis, and a coder may not upgrade "obesity" to "morbid obesity" from a number.

   Source: ICD-10-CM Official Guidelines I.B.14 (documentation by clinicians other than the patient's provider)Report a problem with this question

10. 10. A coder telephones the surgeon and receives a clarification by phone. What must happen for that clarification to be usable for coding?

    • A.The verbal query is recorded and the provider enters the answer in the record.✓ Answer
    • B.The phone call is enough; verbal answers need no written record if witnessed.
    • C.The coder sends the answer to the compliance officer for approval before coding.
    • D.The coder documents the answer in the coding notes and assigns the code from it.

    Verbal queries are permitted, but they must be documented and tracked exactly like written ones, including the date, the person querying, the indicators presented, and any options offered. The answer becomes codeable only when the provider records it in the health record, because a diagnosis that lives only in a coder's notes is not part of the record the claim rests on.

    Source: AHIMA/ACDIS Compliant Query Practice (2022 Update) — verbal queries and documentation of the responseReport a problem with this question

11. 11. Which statement about where a query is kept and when it is issued is correct?

    • A.Queries are issued after the claim is submitted so coding is not delayed by them.
    • B.Queries are kept in the health record or the business record, per policy.✓ Answer
    • C.Queries must always be scanned into the legal health record in every organization.
    • D.Queries are working papers and are discarded once the encounter has been billed.

    Every query must be either a permanent part of the health record or retrievable in the business record, because queries are discoverable and are reviewed in audits; which of the two applies is set by organizational policy and state retention law, not by a single national rule. The Standards of Ethical Coding also place the query before final code assignment, so routinely querying after the claim goes out is backwards.

    Source: AHIMA/ACDIS Compliant Query Practice (2022 Update) — query retention; AHIMA Standards of Ethical Coding Standard 4Report a problem with this question

12. 12. A query has been open for a week with no provider response. What is the appropriate next step?

    • A.Close the query and note that the provider declined to answer the question.
    • B.Assign the code the coder believes the provider would have chosen if asked.
    • C.Ask a physician advisor to answer the query in place of the treating provider.
    • D.Follow the organization's escalation policy for unanswered queries.✓ Answer

    The escalation path for unanswered queries is an organizational responsibility that policy must define, typically moving from a reminder to the department chair or a physician advisor and ultimately to medical staff leadership. Assumption coding fills the gap with the coder's guess, closing the query with an accusation misstates the facts, and a physician advisor may push for a response but cannot supply the diagnosis for the treating provider.

    Source: AHIMA/ACDIS Compliant Query Practice (2022 Update) — organizational query policy and escalationReport a problem with this question

13. 13. Which statement best distinguishes fraud from abuse in healthcare billing?

    • A.Fraud is found by an external auditor and abuse only by an internal auditor.
    • B.Fraud requires a knowing, willful misrepresentation; abuse lacks that intent element.✓ Answer
    • C.Fraud involves federal payers only, while abuse involves commercial payers only.
    • D.Fraud is billing a service twice, while abuse is billing a service never rendered.

    Fraud is a knowing and willful misrepresentation made to obtain a benefit to which the party is not entitled, while abuse describes practices inconsistent with sound fiscal, business, or medical practice that cause unnecessary cost without that state of mind. Both can occur with any payer and both can surface in either an internal or an external review, so intent, not the payer or the finder, is the dividing line.

    Source: OIG/CMS definitions of fraud and abuse; False Claims Act standard of "knowingly"Report a problem with this question

14. 14. A computer-assisted coding system suggests codes from the note. What is the credentialed coder's responsibility?

    • A.Accept the suggestions, since the system applies the guidelines automatically.
    • B.Validate each suggested code against the documentation before the claim goes out.✓ Answer
    • C.Accept the suggestions and query only when the software flags a documentation gap.
    • D.Reject the suggestions and code the record from scratch to avoid software errors.

    Validating codes assigned by a provider or generated by an electronic system is an explicit competency of the credential, because natural-language extraction produces suggestions and not decisions. Accountability for the code that reaches the claim stays with the human coder, who must confirm that the documentation supports each code and query when it does not; discarding the tool entirely is not required and wastes its value.

    Source: AHIMA CCA Exam Content Outline (2022), Domain 4 task 2 and Domain 5; AHIMA Standards of Ethical Coding Standard 3Report a problem with this question

15. 15. During a self-audit, a coder finds that a paid claim carried a diagnosis code the record never supported. What is the correct response?

    • A.Ask the provider to add documentation now so the original claim is supported.
    • B.Report the finding to the OIG before telling anyone inside the facility.
    • C.Correct the code on future claims and leave the paid claim as it stands.
    • D.Correct the claim and report and return the identified overpayment.✓ Answer

    An identified overpayment must be reported and returned within the deadline set by the Affordable Care Act's overpayment rule, so silently fixing the practice going forward leaves a known false claim outstanding. Adding documentation after the fact to justify a code already billed is falsification rather than correction, and internal reporting through the compliance program precedes any decision about external self-disclosure.

    Source: ACA 60-day overpayment rule (42 U.S.C. 1320a-7k(d)); AHIMA Standards of Ethical Coding Standards 1 and 5Report a problem with this question

16. 16. A coder reports separate codes for each component of a procedure that one comprehensive code fully describes. This practice is best described as:

    • A.Downcoding, because the reported codes understate the service performed.
    • B.Duplicate billing, because the same service was submitted on two claims.
    • C.Upcoding, because a higher-paying code was chosen over the documented one.
    • D.Unbundling, because the parts were billed separately, not as one code.✓ Answer

    Unbundling, sometimes called exploding a charge, means reporting the individual components of a bundled service so the total payment exceeds what the comprehensive code would have produced, and it is a long-standing target of procedure-to-procedure edits and government audits. Upcoding substitutes a more severe or higher-paying code for the documented one, downcoding understates the service, and duplicate billing submits the identical service more than once.

    Source: OIG Compliance Program Guidance — coding and billing risk areas; NCCI procedure-to-procedure edit policyReport a problem with this question

17. 17. A recovery audit contractor sends an additional documentation request for 20 inpatient records. Which action is appropriate while preparing the response?

    • A.Delay the response until the appeal of an unrelated denial has been decided.
    • B.Send the requested records, verified complete and authenticated, and log the disclosure.✓ Answer
    • C.Send the complete chart and prior admissions so the auditor has full context.
    • D.Ask providers to add late entries that strengthen the documentation before sending.

    Preparing for an external audit means confirming that each requested record is complete and authenticated, releasing exactly what the request covers, and logging the disclosure, while tracking the response deadline that the request sets. Adding or altering documentation after a request is falsification, sending unrequested records enlarges the audit's scope for no benefit, and missing the deadline is itself treated as a denial-worthy failure to respond.

    Source: AHIMA CCA Exam Content Outline (2022), Domain 4 task 8; CMS RAC additional documentation request processReport a problem with this question

18. 18. Reviewing progress notes, a coder sees the same paragraph, including "day 2 post-op," repeated word for word across five daily notes. What is the concern?

    • A.Copied text is acceptable whenever the provider signs each of the daily notes.
    • B.Copied text must be deleted by the coder from the electronic health record.
    • C.Copied text may not reflect that day's care and cannot support the codes.✓ Answer
    • D.Copied text is a HIPAA violation and must be reported as a privacy breach.

    Copy-forward or cloned documentation is a recognized audit risk because identical text carried from day to day cannot show the patient's condition or the care actually delivered on each date, leaving the codes without genuine support. The remedy is to query the provider and route the pattern to compliance for education; a coder never edits or deletes clinical documentation, and a signature attests to a note but does not make copied content accurate.

    Source: AHIMA Standards of Ethical Coding Standard 3; OIG guidance on cloned/copy-forward documentationReport a problem with this question

19. 19. A supervisor tells a coder to assign a more severe code than the documentation supports because the department is behind on revenue. Per the AHIMA Standards of Ethical Coding, the coder should:

    • A.Assign the code as instructed and note the supervisor's direction in the record.
    • B.Resign from the position quietly rather than take part in the coding practice.
    • C.Assign the code once now, then raise the issue at the next departmental meeting.
    • D.Refuse to assign the unsupported code and report the direction to the compliance office.✓ Answer

    The Standards require a coding professional to refuse to participate in or support any activity intended to skew or misrepresent reported data, and separately forbid concealing unethical coding practices, which means the coder must both decline and report through the compliance program's reporting channel or hotline. Compliance programs are built with non-retaliation protection precisely so this report can be made, and complying "just once" still produces a false claim.

    Source: AHIMA Standards of Ethical Coding Standards 5 and 11; OIG compliance program element on reportingReport a problem with this question

20. 20. To reduce audit attention, a facility tells coders to leave off documented secondary diagnoses. This instruction:

    • A.It is acceptable, because omitting codes cannot cause an overpayment.
    • B.It is acceptable when the omitted conditions do not change the payment group.
    • C.It is contrary to the duty to report all required data and must be refused.✓ Answer
    • D.It is a reasonable risk-control step when the payer's audit rate rises.

    The Standards require coders to gather and report all data required for internal and external reporting in accordance with applicable requirements and data set definitions, so deliberately omitting a supported diagnosis is as much a data-integrity violation as adding an unsupported one. Under-reporting corrupts severity, quality, and public-health data even when the payment group is unchanged, and a coder is directed to refuse any instruction meant to skew reported data.

    Source: AHIMA Standards of Ethical Coding Standards 2 and 5Report a problem with this question

21. 21. An internal coding audit shows a 12% error rate concentrated in one service line. What should follow?

    • A.Recode the sampled records only, since the rest of the claims were not reviewed.
    • B.Report the error rate to the payer and wait for its instructions on next steps.
    • C.Educate the coders and providers involved and re-audit to confirm the fix.✓ Answer
    • D.Raise the coders' productivity target so more records are reviewed each day.

    Auditing and monitoring is only one element of an effective compliance program; the element that closes the loop is prompt corrective action, which means analyzing the root cause, educating the coders and the providers whose documentation drove the errors, correcting affected claims, and re-auditing to prove the fix held. Raising productivity targets attacks the wrong variable, and an internal audit finding is worked through the organization's own compliance process rather than handed to the payer for direction.

    Source: OIG Compliance Program Guidance — internal auditing and monitoring; prompt corrective action elementReport a problem with this question

22. 22. Why must the chargemaster be reviewed each time annual code set updates are released?

    • A.The chargemaster replaces the coder's work on inpatient records at discharge.
    • B.The chargemaster sets the payment rate, so old lines lower the fee schedule.
    • C.Payers reject the entire chargemaster file when a single line is left stale.
    • D.Hard-coded lines bill automatically, so a deleted code generates wrong claims.✓ Answer

    Many chargemaster lines carry a hard-coded procedure code that drops onto the claim without a coder ever touching the encounter, so a deleted, invalid, or mismatched code keeps producing defective claims on every visit until someone corrects the file. Researching and implementing coding changes on the chargemaster and the fee ticket is therefore a named compliance duty, not an optional housekeeping task; the file holds charges but does not set what a payer pays.

    Source: AHIMA CCA Exam Content Outline (2022), Domain 4 tasks 5 and 6 (fee/charge ticket and chargemaster updates)Report a problem with this question

Practice questions based on the AHIMA Certified Coding Associate (CCA) Exam Content Outline, the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting, and the AHIMA Standards of Ethical Coding. This site is not affiliated with or endorsed by AHIMA. Code sets and their official guidelines are revised every year, so no question here keys a specific code value — always assign codes from the current code books, encoder and official guidelines in effect for the date of service, never from a practice test. Confirm current eligibility and exam requirements with AHIMA before you test. About the CCA credential →