Free AAPC CIC Practice Test: 40 Questions and 3 Coding Cases

Answer: B. A41.9, J18.9

When the reason for admission is sepsis and a localized infection such as pneumonia, the systemic infection code goes first and the localized infection is a secondary diagnosis. A41.9 (sepsis, unspecified organism) is followed by J18.9 (pneumonia, unspecified organism).

• A: Puts the localized infection first. That order applies when the patient is admitted for the localized infection and sepsis develops after admission.
• C: R65.2- codes are never sequenced first, and severe sepsis is not documented here.
• D: R65.20 is for severe sepsis. Without documented acute organ dysfunction associated with the sepsis, severe sepsis is not coded.

Source: 2026 ICD-10-CM Official Guidelines, Section I.C.1.d.4 and Section I.C.1.d.1.b; CMS, original 2026 ICD-10-CM Tabular List and Alphabetic Index (ZIP) (A41.9, J18.9 and R65.20).

Answer: C. I13.0, I50.23, N18.4

ICD-10-CM presumes a causal relationship between hypertension and heart involvement and between hypertension and CKD unless documentation clearly says the conditions are unrelated. When both hypertensive heart disease and hypertensive CKD are present, a code from combination category I13 is assigned. I13.0 covers heart failure with stage 1 through 4 CKD. The Tabular List sequences it first: I50 carries a "code first" note for heart failure due to hypertension with CKD (I13.-), and I13.0 says to use additional codes for the type of heart failure (I50.23) and the CKD stage (N18.4).

• A: I10 would be used only if the provider documented that the hypertension was unrelated to both conditions. Here no such statement exists.
• B: I11.0 captures only the heart component and leaves out the presumed link to CKD.
• D: Ignores the combination code required when both heart and kidney involvement are present, and leads with the manifestation.

Source: 2026 ICD-10-CM Official Guidelines, Section I.C.9.a.3; CMS, original 2026 ICD-10-CM Tabular List and Alphabetic Index (ZIP) (I13.0 and the I50/N18 sequencing notes).

Answer: A. Code pneumonia (J18.9) as if it were established

For inpatient admissions, a diagnosis documented at discharge as probable, suspected, likely or a similar uncertain term is coded as if it existed or was established. This rule is specific to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals; it does not apply to outpatient encounters.

• B: The inpatient guideline directs you to code the uncertain diagnosis; a query is not required just because the word "probable" appears.
• C: Coding symptoms only is the outpatient approach to uncertain diagnoses, not the inpatient rule.
• D: The condition was not ruled out; it was documented as probable and treated.

Source: 2026 ICD-10-CM Official Guidelines, Section II.H (p. 109) and Section III.C (p. 111); CMS, original 2026 ICD-10-CM Tabular List and Alphabetic Index (ZIP) (J18.9 and Z03).

Answer: C. 0DTJ4ZZ

Removing all of a body part without replacement is the root operation Resection (T). The appendix is body part J in the Gastrointestinal System (D), and laparoscopy is the Percutaneous Endoscopic approach (4). 0DTJ4ZZ = Resection of Appendix, Percutaneous Endoscopic Approach.

• A: Approach 0 is Open; a laparoscopic procedure is Percutaneous Endoscopic.
• B: Excision (B) means removing only a portion of a body part.
• D: 0DJD4ZZ is Inspection of the lower intestinal tract, Percutaneous Endoscopic Approach; it does not describe removal of the appendix. Inspection performed to achieve the objective of this appendectomy is not coded separately.

Source: 2026 ICD-10-PCS Official Guidelines, B3.1a and B3.11a/c; CMS, original 2026 ICD-10-PCS tables and index (ZIP) (tables 0DT, 0DB and 0DJ).

Answer: A. 0DBL8ZX

Biopsies are coded with the root operation Excision, Extraction or Drainage plus the qualifier X, Diagnostic. A forceps biopsy cuts out a portion of tissue, so the root operation is Excision (B). Body part L is the transverse colon, approach 8 is Via Natural or Artificial Opening Endoscopic, and qualifier X marks it as diagnostic: 0DBL8ZX.

• B: Inspection alone doesn't describe tissue being taken.
• C: Resection would mean removing the entire transverse colon.
• D: Correct root operation, but qualifier Z (no qualifier) loses the diagnostic designation a biopsy requires.

Source: 2026 ICD-10-PCS Official Guidelines, B3.4a; CMS, original 2026 ICD-10-PCS tables and index (ZIP) (tables 0DB, 0DJ and 0DT; 0DBL8ZX).

Answer: D. 5A1945Z

Table 5A1 (Extracorporeal or Systemic Assistance and Performance, Physiological Systems, Performance) reports respiratory ventilation by duration. Fifty consecutive hours falls in the 24 to 96 consecutive hours value: 5A1945Z.

• A: 0BH17EZ reports insertion of an endotracheal airway into the trachea via a natural or artificial opening; it does not report ventilation duration.
• B: 5A1935Z is less than 24 consecutive hours.
• C: 5A1955Z is greater than 96 consecutive hours.

Source: CMS, original 2026 ICD-10-PCS tables and index (ZIP) (tables 5A1 and 0BH; 5A1945Z and 0BH17EZ).

Answer: D. W

POA indicator W means the provider is unable to clinically determine whether the condition was present on admission. U means documentation is insufficient to determine it, which is a reason to query.

• A: U is for insufficient documentation, not a provider's clinical determination that it can't be known.
• B: N means it was not present at the time of admission.
• C: Y means the condition was present at the time of inpatient admission.

Source: 2026 ICD-10-CM Official Guidelines, Appendix I (pp. 116-118)

Answer: D. The obesity diagnosis and the BMI code, using the dietitian's note for the BMI value

Section I.B.14 allows the BMI value to be taken from documentation by clinicians other than the patient's provider, such as a dietitian, but the associated diagnosis (here, obesity) must be documented by the patient's provider. BMI codes are reported only as secondary diagnoses.

• A: No restatement is required when the attending already documents the diagnosis.
• B: A BMI code needs the associated diagnosis from the provider; it is not reported on the dietitian's note alone.
• C: The guideline specifically permits BMI from other clinicians.

Source: 2026 ICD-10-CM Official Guidelines, Section I.B.14

Answer: B. Use the wound care nurse's documentation for the stage, with the ulcer diagnosis from the attending

Pressure ulcer stage is one of the details Section I.B.14 allows coders to take from clinicians other than the patient's provider, as long as the provider documents the associated diagnosis (the pressure ulcer).

• A: Unspecified stage would ignore documentation the guideline lets you use.
• C: The guideline's point is that the clinician documenting the stage is not the patient's provider.
• D: A query is appropriate for conflicting or unclear documentation, not for a stage the guideline already permits from nursing.

Source: 2026 ICD-10-CM Official Guidelines, Section I.B.14

Answer: C. Do not code it from the lab value alone; query the physician if the finding appears clinically significant

Abnormal findings (lab, x-ray, pathology and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending has ordered other tests or treatment, it may be appropriate to ask the provider whether a diagnosis should be added.

• A: Coders do not diagnose from lab values.
• B: POA indicators do not decide whether a condition is reportable, and W means clinically undetermined, not a payment workaround.
• D: An abnormal-findings code still requires the provider to indicate clinical significance.

Source: 2026 ICD-10-CM Official Guidelines, Section III.B (p. 111); CMS, original 2026 ICD-10-CM Tabular List and Alphabetic Index (ZIP) (E87.6 and R79.89).

Answer: B. The provider's diagnostic statement that the condition exists

Section I.A.19 says code assignment is based on the provider's diagnostic statement that the condition exists, and is not based on clinical criteria the provider used to establish the diagnosis. Concerns about clinical support go through the facility's clinical validation and query process, not through the coder silently dropping the diagnosis.

• A: Payment impact never determines whether a documented condition is coded.
• C: The attending's documentation is sufficient on its own.
• D: Coders don't override a documented diagnosis based on their own reading of the clinical criteria.

Source: 2026 ICD-10-CM Official Guidelines, Section I.A.19 (p. 12); ACDIS/AHIMA, Guidelines for Achieving a Compliant Query Practice (2026 Update), Section V.IV (p. 16).

Answer: A. "Laboratory reports show serum creatinine of 1.0 mg/dL on hospital day 1 and 2.4 mg/dL on hospital day 2. The medication administration record shows IV fluids on hospital day 2. Based on your clinical judgment, please clarify the clinical significance, if any, of these findings and the condition being treated."

An open-ended query may present relevant clinical indicators and ask the provider to clarify their clinical significance in free text. A identifies the findings and their sources without proposing a diagnosis or mentioning reimbursement. The provider can explain a diagnosis, a lack of clinical significance, or an inability to determine the answer.

• B: A yes/no query that introduces a new diagnosis not already documented is leading.
• C: Leading, and it states the reimbursement impact.
• D: Mentions financial impact, which a query must not do.

Source: ACDIS/AHIMA, Guidelines for Achieving a Compliant Query Practice (2026 Update), Section V.I.C (pp. 7–8), V.II.B (p. 12) and V.II.C (p. 14).

Answer: A. Atrial fibrillation; the patient's home anticoagulant is continued and the rhythm is monitored

Section III defines other diagnoses as conditions that affect patient care through clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, or increased nursing care and/or monitoring. Continued anticoagulation and rhythm monitoring meet that definition.

• B: A diagnosis that was ruled out is not coded as if it existed.
• C: An abnormal finding without provider-documented significance is not coded.
• D: A resolved condition with no bearing on this stay is not reported.

Source: 2026 ICD-10-CM Official Guidelines, Section III (pp. 110-111)

Answer: B. When a health care provider requests or receives information for treatment

Under 45 CFR 164.502(b), the minimum necessary standard does not apply to disclosures to or requests by a health care provider for treatment. Payment and health care operations disclosures, such as audits and payer reviews, generally must be limited to the minimum necessary.

• A: Payment disclosures are generally subject to minimum necessary.
• C: Internal audits are operations uses, also subject to minimum necessary.
• D: Business associate status does not itself create an exception; ordinary payment disclosures are generally subject to minimum necessary.

Source: 45 CFR 164.502(b), Minimum necessary; HHS, Minimum Necessary Requirement, How the Rule Works.

Answer: A. No more than 30 days before or 24 hours after admission (with an update if done before admission), and before surgery or a procedure requiring anesthesia

42 CFR 482.22(c)(5) requires the H&P to be completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia. An H&P done within the 30 days before admission needs an updated examination, completed and documented within 24 hours after admission and before surgery or a procedure requiring anesthesia.

• B: The H&P requirement applies to every admission, not just surgical ones.
• C: The regulation's window is 24 hours after admission, not 48.
• D: The deadline is tied to admission and any surgery or procedure requiring anesthesia, not to the discharge summary.

Source: 42 CFR 482.22(c)(5), Medical staff bylaws: history and physical timing

Answer: B. Bringing one end of the large intestine out through an opening (stoma) in the abdominal wall

A colostomy brings one end of the large intestine out through an opening in the abdominal wall (a stoma). The suffix -stomy means a surgically created opening; -ectomy is removal, -scopy is viewing with a scope.

• A: That is a colonoscopy.
• C: That is a colectomy (total).
• D: Hernia repair is herniorrhaphy or hernioplasty.

Source: MedlinePlus Medical Encyclopedia, Colostomy; MedlinePlus, medical word endings about procedures; MedlinePlus, medical word endings and procedure examples; NLM MeSH, Herniorrhaphy, definition and entry terms.

Answer: B. Hepatobiliary System and Pancreas (F)

The gallbladder belongs to the Hepatobiliary System and Pancreas, body system F. That is why a complete laparoscopic cholecystectomy is built in table 0FT (for example, 0FT44ZZ, Resection of Gallbladder, Percutaneous Endoscopic Approach), not in the gastrointestinal tables.

• A: Lymphatic and Hemic Systems covers lymph nodes, spleen and related structures.
• C: The Endocrine System covers glands such as the thyroid and adrenals.
• D: The Gastrointestinal System (D) covers the digestive tube from esophagus to anus, including the appendix.

Source: CMS, original 2026 ICD-10-PCS tables and index (ZIP), table 0FT and the body-system headings (0FT44ZZ).

Answer: D. Furosemide is a diuretic used for edema and high blood pressure; it suggests what to look for, but a diagnosis is coded only when the provider documents it

Furosemide is a diuretic used to treat edema and high blood pressure. Knowing that helps you spot conditions worth checking for in the provider's notes (or worth a query), but a medication on a list is never a diagnosis by itself.

• A: Furosemide is not a diabetes medication.
• B: Coders don't assign diagnoses from medications.
• C: Furosemide is not an anticoagulant.

Source: MedlinePlus, Furosemide; 2026 ICD-10-CM Official Guidelines, Section I.A.19.

Answer: D. The attending physician's specialty

MS-DRG grouping uses the principal diagnosis, secondary diagnoses (including complications and comorbidities), procedures, and patient data such as discharge status, age and sex. The physician's specialty is not a grouping input.

• A: Operating room procedures can move a case into a surgical MS-DRG.
• B: The principal diagnosis largely determines the MDC and base DRG.
• C: Qualifying CC and MCC secondary diagnoses can move cases into higher severity levels, subject to the applicable grouping rules and exclusions.

Source: CMS MLN6922507, Medicare Payment Systems: Acute Care Hospital Inpatient PPS (Acute Care Hospital Inpatient PPS section); CMS, Design and Development of the Diagnosis Related Group system (pp. 8–10); CMS FY2026 MS-DRG Definitions Manual v43.0, Appendix H.

Answer: A. A diagnosis designated as an MCC

MS-DRGs can be split into "with MCC," "with CC" and "without CC/MCC" levels. In a three-level family, a qualifying secondary MCC supports the highest severity level. CC exclusions and other applicable grouping rules must be applied.

• B: An additional diagnosis does not automatically have a CC or MCC designation.
• C: A qualifying CC supports the middle severity level, rather than the MCC level.
• D: A code designated as neither a CC nor an MCC does not establish one of those severity levels. The Z-code chapter alone does not determine CC/MCC status.

Source: CMS MLN6922507, Medicare Payment Systems: Acute Care Hospital Inpatient PPS (Acute Care Hospital Inpatient PPS section); CMS FY2026 MS-DRG Definitions Manual v43.0, Appendix H; CMS FY2026 MS-DRG Definitions Manual v43.1, CC/MCC code list (status-code examples).

Answer: D. The hospital receives no additional payment for it; the case is paid as if that secondary diagnosis were not present

Stage III and IV pressure ulcers are a CMS HAC category. When a selected HAC is not present on admission, the hospital does not receive additional payment for it, so the condition can't push the case into a higher-paying group. The condition is still coded.

• A: This provision removes the selected HAC's effect on MS-DRG payment; it does not deny the entire claim.
• B: Stage III and IV pressure ulcers are on the HAC list.
• C: The HAC provision removes added payment; it doesn't create one.

Source: CMS, Hospital-Acquired Conditions (HAC) payment provision

Answer: B. Bundled onto the inpatient claim under the payment window rule

Under Medicare's three-calendar-day payment window, covered outpatient diagnostic services and related non-diagnostic services provided by the admitting IPPS hospital, or an entity it wholly owns or operates, on the admission date or during the three preceding calendar days are included on the inpatient claim. Certain non-IPPS hospitals use a one-calendar-day window. The policy does not apply when the admitting hospital is a critical access hospital.

• A: The hospital's diagnostic laboratory charge in this scenario is included on the inpatient claim.
• C: Diagnostic services in the window are not billed separately.
• D: The payment-window rule bundles this covered service; it does not turn it into a noncovered patient charge.

Source: 42 CFR 412.2, Basis of payment (payment window, 412.2(c)(5)); CMS MLN Matters SE20024, Updated FAQs on Medicare’s 3-Day Payment Window (pp. 1–3).

Answer: D. When the admitting physician expects the patient to require hospital care that crosses two midnights

42 CFR 412.3(d)(1) states that an inpatient admission is generally appropriate when the admitting physician expects the patient to require hospital care that crosses two midnights, supported by the complex medical factors documented in the record. Procedures on the inpatient-only list and case-by-case exceptions are handled separately.

• A: Mode of arrival doesn't determine status.
• B: Many surgeries are performed on an outpatient basis.
• C: Observation length alone doesn't make the stay inpatient.

Source: 42 CFR 412.3, Admissions

Answer: A. A per diem-based payment that can be less than the full MS-DRG amount

Under the post-acute care transfer policy, CMS reduces the MS-DRG payment for qualifying MS-DRGs when the length of stay is at least 1 day less than the geometric mean length of stay and the patient goes to a post-acute setting such as a SNF or qualifying home health services that begin within 3 days after discharge. Under the standard transfer formula, payment is a graduated per diem, with the first day paid at double the per diem, capped at the full MS-DRG amount. Certain qualifying MS-DRGs use a special transfer-payment formula.

• B: A short stay alone does not establish outlier eligibility. A transfer case can also qualify for an outlier payment if its costs meet the separate outlier criteria.
• C: The stay is payable, just adjusted.
• D: That ignores the transfer adjustment.

Source: 42 CFR 412.4, Discharges and transfers, paragraphs (c) and (f); 42 CFR 412.80, Outlier cases, paragraph (b).

Answer: B. An additional payment for cases with extraordinarily high costs above a fixed-loss threshold

IPPS outlier payments supplement the MS-DRG payment when a case's costs exceed a fixed-loss cost threshold, protecting hospitals from extraordinarily costly cases.

• A: Readmission penalties come from a separate program.
• C: New technology add-on payment is a separate mechanism.
• D: Geography is not the outlier test.

Source: 42 CFR 412.80, Outlier cases

Answer: B. Inpatient Rehabilitation Facility PPS

The IRF PPS assigns patients to case-mix groups based on information from the IRF Patient Assessment Instrument (IRF-PAI). LTCHs are paid using MS-LTC-DRGs, acute care hospitals using MS-DRGs, and hospital outpatient services using APCs.

• A: Acute care IPPS uses MS-DRGs.
• C: OPPS uses APCs.
• D: LTCH PPS uses MS-LTC-DRGs.

Source: CMS, Inpatient Rehabilitation Facility PPS; CMS MLN6922507, Medicare Payment Systems: Acute Care Hospital Inpatient PPS (Acute Care Hospital Inpatient PPS section) (IRF Payment Rates and LTCH patient classifications).

Answer: C. The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care

Section II quotes the UHDDS definition: the condition established after study to be chiefly responsible for occasioning the admission. "After study" means the coder looks at the whole stay, not just the admitting impression.

• A: Payment never determines the principal diagnosis.
• B: The ED impression may change after study.
• D: Severity isn't the test; the reason for admission is.

Source: 2026 ICD-10-CM Official Guidelines, Section II (pp. 107-108)

Answer: C. UB-04 (CMS-1450) / 837I

Institutional providers, including hospitals billing inpatient stays, use the UB-04 (CMS-1450) paper form or its electronic counterpart, the 837I. The CMS-1500/837P is the professional claim used for physician services.

• A: Pharmacy only.
• B: Professional claim, used for physician services.
• D: Dental only.

Source: CMS MLN006926, 837I and Form CMS-1450 (UB-04), Dec 2025 (pp. 3–4); CMS, Adopted Standards and Operating Rules.

Answer: C. Ambulatory Payment Classifications (APCs)

OPPS groups services into Ambulatory Payment Classifications, clinically and resource-similar groups that each carry a payment rate. That contrasts with inpatient IPPS, which pays one MS-DRG amount per stay.

• A: MS-DRGs are the inpatient system.
• B: CMGs are used by inpatient rehabilitation facilities.
• D: RVUs are used to calculate Physician Fee Schedule payment; APCs are the classification used by OPPS.

Source: CMS MLN6922507, Medicare Payment Systems: Hospital Outpatient PPS (APCs, packaging, transitional pass-through); CMS, Physician Fee Schedule.

Answer: C. The item or service is packaged into the APC payment for other services, with no separate payment

Status indicator N identifies items and services packaged into APC rates; they are reported but not paid separately.

• A: New-technology APCs use different status indicators.
• B: Packaged is not the same as non-covered.
• D: Inpatient-only procedures carry a different status indicator (C).

Source: CMS Medicare Claims Processing Manual, Chapter 4: hospital outpatient services, Section 10.1.1 (PDF pp. 16–17); CMS Transmittal 13686, April 2026 OPPS update (PDF pp. 4 and 8); CMS MLN MM14361, January 2026 OPPS update (p. 4).

Answer: D. Extra payments for certain new drugs, biologicals and devices for a limited period

Pass-through payments are temporary additional OPPS payments for certain new drugs, biologicals and medical devices while CMS develops the cost data needed for rate setting.

• A: Not a cost-shifting mechanism.
• B: Pass-through status is transitional and limited to qualifying items.
• C: Payments go to the hospital.

Source: CMS MLN6922507, Medicare Payment Systems: Hospital Outpatient PPS (APCs, packaging, transitional pass-through); CMS MLN MM14361, January 2026 OPPS update (transitional pass-through payments and offsets).

Answer: C. Being formally admitted under an inpatient admission order from a qualified physician or practitioner

Under 42 CFR 412.3, a patient is an inpatient once formally admitted pursuant to an order for inpatient admission by a physician or other qualified practitioner. Hours in the building, bed location and procedures do not change status on their own; time in observation before the order is outpatient.

• A: Observation patients can be placed on inpatient units.
• B: A long observation stay is still outpatient.
• D: Surgery can be outpatient.

Source: 42 CFR 412.3, Admissions

Answer: A. The Medicare Outpatient Observation Notice (MOON), no later than 36 hours after observation services begin, or sooner if the patient is transferred, discharged, or admitted as an inpatient

The MOON informs beneficiaries receiving observation for more than 24 hours that they are outpatients, not inpatients, and explains the implications. It must be delivered no later than 36 hours after observation services begin, or sooner if the patient is transferred, discharged, or admitted as an inpatient.

• B: An ABN addresses services expected to be denied, not observation status.
• C: Observation over 24 hours triggers the MOON requirement.
• D: The Important Message is for inpatients.

Source: 42 CFR 489.20(y), Medicare outpatient observation notice; CMS fact sheet, Medicare Outpatient Observation Notice (MOON).

Answer: A. Within 2 calendar days of admission

Hospitals deliver the IM, which explains inpatient rights including the right to appeal a discharge, within 2 calendar days of admission and deliver a follow-up copy no more than 2 calendar days before discharge (with limited exceptions).

• B: Post-discharge delivery defeats the purpose of the notice.
• C: The IM is required regardless of an appeal request.
• D: The initial notice is due at or near admission. A follow-up copy is generally provided before discharge unless the initial notice already falls within the two-calendar-day discharge window.

Source: 42 CFR 405.1205, Notifying beneficiaries of hospital discharge appeal rights

Answer: A. A physician or other practitioner authorized by state law and hospital bylaws to admit inpatients, with admitting privileges and knowledge of the patient's hospital course

The order must come from a physician or other practitioner who is licensed by the state and has admitting privileges under hospital bylaws and staff rules, and who is knowledgeable about the patient's hospital course, medical plan of care and current condition.

• B: The committee's utilization-review role does not itself confer authority to order admission.
• C: Patients consent to care; they don't order admission.
• D: Being a registered nurse on the unit does not by itself confer the state authority and hospital admitting privileges required by this rule.

Source: 42 CFR 412.3, Admissions

Answer: C. Actual knowledge, deliberate ignorance, or reckless disregard of the truth or falsity of the information

The False Claims Act defines "knowingly" to include actual knowledge, deliberate ignorance and reckless disregard, and it states that no proof of specific intent to defraud is required.

• A: The statute expressly says specific intent is not required.
• B: There is no dollar floor for liability.
• D: Liability reaches anyone who knowingly presents or causes a false claim.

Source: 31 U.S.C. 3729, False claims (official 2024 U.S. Code edition), Section 3729(b)(1) (PDF pp. 10–11); HHS-OIG General Compliance Program Guidance (November 2023), Section II.C (pp. 17–18).

Answer: D. Designation of a compliance officer and compliance committee

OIG's seven elements are: written policies and procedures; compliance leadership and oversight (a compliance officer and committee); training and education; effective lines of communication with the compliance officer and disclosure programs; enforcing standards through consequences and incentives; risk assessment, auditing and monitoring; and responding to detected offenses and developing corrective action.

• A: Compliant queries are part of accurate documentation, not something to eliminate.
• B: Reimbursement must not override accurate, supported coding. Assigning an unsupported higher-paying MS-DRG is upcoding.
• C: Guaranteed coding bonuses are not one of OIG's seven elements; the guidance discusses incentives that support compliance.

Source: HHS-OIG General Compliance Program Guidance (November 2023), Section III; HHS-OIG, A Roadmap for New Physicians: Physician relationships with payers (Accurate coding and billing).

Answer: C. Federal health care programs generally won't pay for items or services the excluded person furnishes, and the employer can face civil monetary penalties

Federal health care programs generally cannot pay for items or services furnished, ordered or prescribed by an excluded person. A provider that knows or should know of the exclusion may face civil monetary penalties for employing or contracting with that person to furnish federally payable services, including related administrative work. LEIE screening and verification of potential identity matches help identify this risk.

• A: Exclusion effects reach administrative and support roles connected to federally reimbursed services.
• B: Supervision does not lift an exclusion.
• D: The employer bears the payment and penalty risk.

Source: HHS-OIG, Background Information on Exclusion Authorities; HHS-OIG, Updated Special Advisory Bulletin on the Effect of Exclusion (pp. 7–8, 11 and 13–14).

Answer: B. A query should not indicate the impact on reimbursement or quality measures

Compliant query guidance says queries must not be leading and must not indicate the financial or quality-reporting impact of a response. Multiple-choice queries offer clinically reasonable options supported by the record.

• A: Stating financial impact makes a query noncompliant.
• C: Queries can occur concurrently, before billing, or retrospectively.
• D: Multiple-choice queries must allow an alternative explanation, such as an "other" or open-ended response. One supported diagnosis choice is not automatically leading.

Source: ACDIS/AHIMA, Guidelines for Achieving a Compliant Query Practice (2026 Update), Sections V.I.B, V.II.A and VIII.

Answer: D. Upcoding

OIG describes upcoding as using billing codes that reflect a more severe illness than actually existed, or a more expensive service than was provided. Choosing an unsupported, higher-severity diagnosis to raise payment is exactly that, and it can make a claim false.

• A: A query asks the provider to clarify; the coder here simply assigned the unsupported code.
• B: Clinical validation is a review of whether a documented diagnosis is supported; it doesn't add severity the provider never documented.
• C: Downcoding is reporting a lower level than the documentation supports, the opposite direction.

Source: HHS-OIG, A Roadmap for New Physicians: Physician relationships with payers (Accurate coding and billing)