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Section 1
principal diagnosis selection — Apply the UHDDS definition of principal diagnosis in an acute-care inpatient scenario.
Preview
Preview: ICD-10-CM inpatient diagnosis coding
Preview includes- 2 of 2 lesson topics
- 1 overview segment
- 3 core concepts
- 2 exam tips
Lesson Topics
- principal diagnosis selection
- Apply the UHDDS definition of principal diagnosis in an acute-care inpatient scenario.
Overview
The UHDDS principal-diagnosis definition is based on the condition established after study to be chiefly responsible for occasioning the inpatient admission, not on which condition later consumes the most resources.
Core Concepts
- Rule: The UHDDS principal-diagnosis definition is based on the condition established after study to be chiefly responsible for occasioning the inpatient admission, not on which condition later consumes the most resources.
- Correct application: Acute calculous cholecystitis, because it was established after study as chiefly responsible for the admission.
- Source anchor: FY 2026 ICD-10-CM conventions, principal diagnosis selection, additional diagnosis reporting, chapter-specific rules, inpatient uncertain diagnoses, and POA guidance.
Exam Tips
- Anchor on the tested concept: principal diagnosis selection.
- Do not let severity, resource use, or expected reimbursement override an explicit coding/classification rule.
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Section 2
secondary diagnoses — Apply the UHDDS criteria for reporting additional diagnoses.
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Section 3
present on admission — Apply the CMS definition of present on admission.
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Section 4
official inpatient diagnosis guidelines — Apply the hierarchy of ICD-10-CM conventions and official guidelines.
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Section 5
uncertain diagnoses in inpatient settings — Apply the inpatient uncertain-diagnosis rule at discharge.
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Section 6
combination codes and sequencing — Apply combination-code conventions without redundant coding.
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Section 7
principal diagnosis selection — Apply the original-treatment-plan-not-carried-out rule.
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Section 8
secondary diagnoses — Identify a reportable secondary diagnosis based on impact on care.
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Section 9
present on admission — Assign POA conceptually when a condition develops after inpatient admission.
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Section 10
official inpatient diagnosis guidelines — Apply the definitive-diagnosis-versus-symptom rule.
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Section 11
uncertain diagnoses in inpatient settings — Apply uncertain-diagnosis coding to a suspected condition at inpatient discharge.
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Section 12
combination codes and sequencing — Apply etiology/manifestation sequencing instructions.
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Section 13
principal diagnosis selection — Select principal diagnosis when the admission is for a complication of care.
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Section 14
secondary diagnoses — Apply the inpatient rule for abnormal diagnostic findings.
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Section 15
present on admission — Distinguish POA value U from Y, N, and W after clarification remains insufficient.
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Section 16
official inpatient diagnosis guidelines — Apply the rule for clinically insignificant abnormal findings.
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Section 17
uncertain diagnoses in inpatient settings — Distinguish an uncertain discharge diagnosis from a condition ruled out before discharge.
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Section 18
combination codes and sequencing — Differentiate adverse-effect sequencing from poisoning and underdosing.
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Section 19
principal diagnosis selection — Apply the rule for two interrelated conditions potentially meeting the principal-diagnosis definition.
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Section 20
secondary diagnoses — Distinguish reportable additional diagnoses from irrelevant previous conditions.
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Section 21
present on admission — Apply the provider-unable-to-clinically-determine POA concept.
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Section 22
official inpatient diagnosis guidelines — Apply ICD-10-CM Tabular instructions for a 'code also' note.
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Section 23
uncertain diagnoses in inpatient settings — Differentiate inpatient and outpatient uncertain-diagnosis rules.
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Section 24
combination codes and sequencing — Differentiate poisoning from adverse effect and apply sequencing logic.
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Section 25
principal diagnosis selection — Apply the rule for two diagnoses that equally meet the principal-diagnosis definition.
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Section 26
secondary diagnoses — Determine when a historical condition has current inpatient coding relevance.
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Section 27
present on admission — Apply the POA-exempt-code rule.
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Section 28
official inpatient diagnosis guidelines — Apply full-code and specificity requirements in ICD-10-CM.
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Section 29
uncertain diagnoses in inpatient settings — Apply the rule for comparative or contrasting inpatient discharge diagnoses.
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Section 30
combination codes and sequencing — Apply underdosing coding concepts.
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Section 31
principal diagnosis selection — Select principal diagnosis after outpatient surgery when a complication causes inpatient admission.
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Section 32
secondary diagnoses — Separate additional-diagnosis reportability from POA status.
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Section 33
present on admission — Know the scope of CMS POA indicator reporting.
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Section 34
official inpatient diagnosis guidelines — Identify when conflicting provider documentation requires clarification.
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Section 35
uncertain diagnoses in inpatient settings — Recognize qualifying terms covered by the inpatient uncertain-diagnosis guideline.
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Section 36
combination codes and sequencing — Apply combination-code plus additional-code instructions.
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Section 37
principal diagnosis selection — Apply principal-diagnosis rules when an observation stay converts to inpatient.
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Section 38
secondary diagnoses — Apply additional-diagnosis criteria to a chronic comorbidity.
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Section 39
present on admission — Apply POA timing across observation-to-inpatient conversion.
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Section 40
official inpatient diagnosis guidelines — Use the final diagnostic statement when a working diagnosis is ruled out.
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Section 41
uncertain diagnoses in inpatient settings — Apply uncertain-diagnosis rules when diagnostic testing is not definitive.
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Section 42
combination codes and sequencing — Apply the hypertension-with-CKD presumption and additional-stage coding.
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Section 43
principal diagnosis selection — Apply the rehabilitation principal-diagnosis rule.
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Section 44
secondary diagnoses — Distinguish provider-documented diagnoses from isolated abnormal findings.
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Section 45
present on admission — Integrate inpatient uncertain-diagnosis and POA rules.
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Section 46
official inpatient diagnosis guidelines — Apply provider-documentation requirements for diagnosis assignment.
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Section 47
uncertain diagnoses in inpatient settings — Interpret 'still to be ruled out' correctly in an inpatient discharge diagnosis.
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Section 48
combination codes and sequencing — Apply HIV-related inpatient sequencing guidance.
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Section 49
principal diagnosis selection — Distinguish the reason for admission from conditions arising during the stay.
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Section 50
secondary diagnoses — Recognize increased nursing care as a criterion for an additional diagnosis.
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Section 51
seven-character PCS structure — Identify the seven-character structure of ICD-10-PCS.
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Section 52
root operation selection — Select the correct root operation when an entire body part is removed.
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Section 53
body part and approach — Map laparoscopic terminology to the PCS approach axis.
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Section 54
device and qualifier — Apply the PCS definition of a device that remains after the procedure.
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Section 55
multiple procedures — Apply multiple-procedure rules to the same root operation on different body parts.
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Section 56
PCS guidelines — Recognize integral procedural steps that are not coded separately.
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Section 57
medical/surgical and ancillary sections — Distinguish Obstetrics procedures from Medical and Surgical procedures.
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Section 58
seven-character PCS structure — Validate a PCS code using the Index and Tables.
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Section 59
medical necessity/utilization concepts — Evaluate documentation supporting medical necessity and utilization.
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Section 60
body part and approach — Identify the Open approach from operative documentation.
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Section 61
device and qualifier — Recognize integral materials that are not coded as PCS devices.
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Section 62
multiple procedures — Code a biopsy followed by definitive treatment at the same site.
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Section 63
PCS guidelines — Code a discontinued procedure based on the objective actually accomplished.
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Section 64
medical/surgical and ancillary sections — Select the Obstetrics section for postpartum treatment of retained products of conception.
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Section 65
seven-character PCS structure — Use the PCS Index and Tables correctly.
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Section 66
root operation selection — Distinguish Excision from Resection.
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Section 67
body part and approach — Select the correct approach for endoscopy through a natural opening.
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Section 68
device and qualifier — Capture a drainage device left in place after a Drainage procedure.
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Section 69
multiple procedures — Apply separate coding for one root operation on distinct body parts.
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Section 70
PCS guidelines — Apply the Control root operation appropriately for bleeding.
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Section 71
medical/surgical and ancillary sections — Apply section guidance when a New Technology code fully describes a procedure.
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Section 72
seven-character PCS structure — Resolve incomplete documentation needed to construct a PCS code.
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Section 73
root operation selection — Select Extirpation when solid matter is removed from a body part.
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Section 74
body part and approach — Apply the External approach to closed fracture reduction.
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Section 75
device and qualifier — Distinguish procedural instruments from devices that remain.
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Section 76
multiple procedures — Code a procedure converted from percutaneous endoscopic to open.
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Section 77
PCS guidelines — Choose Resection when an entire specifically defined body part is removed.
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Section 78
medical/surgical and ancillary sections — Select a principal procedure when definitive procedures treat principal and secondary diagnoses.
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Section 79
seven-character PCS structure — Recognize the ICD-10-PCS character set.
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Section 80
root operation selection — Distinguish Fragmentation from Extirpation.
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Section 81
body part and approach — Determine approach when an incision is extended only for specimen removal.
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Section 82
device and qualifier — Use the correct device-related root operation for implanted equipment.
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Section 83
multiple procedures — Determine code count for biopsies on distinct body parts.
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Section 84
PCS guidelines — Recognize when a procedure through a natural opening is coded External.
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Section 85
medical/surgical and ancillary sections — Apply principal-procedure sequencing when the principal diagnosis receives only a diagnostic procedure.
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Section 86
seven-character PCS structure — Interpret PCS character values in context rather than treating Z as a universal default.
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Section 87
root operation selection — Apply the Release root operation to decompression procedures.
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Section 88
body part and approach — Differentiate Percutaneous from Percutaneous Endoscopic access.
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Section 89
device and qualifier — Select Removal for taking out a previously placed device.
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Section 90
multiple procedures — Apply multiple-procedure rules to coronary bypasses with different graft sources.
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Section 91
PCS guidelines — Address missing documentation for a required PCS character.
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Section 92
medical/surgical and ancillary sections — Select the principal procedure when no procedure treats the principal diagnosis.
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Section 93
seven-character PCS structure — Interpret a PCS Z value correctly in the device axis.
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Section 94
root operation selection — Select Drainage for evacuation of fluid from a body part.
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Section 95
body part and approach — Apply the deepest-layer body-part rule for excisional debridement.
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Section 96
device and qualifier — Distinguish Revision from Removal and initial device placement.
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Section 97
multiple procedures — Determine when a separate autograft-harvest code is required.
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Section 98
PCS guidelines — Translate clinical documentation into PCS terminology without requiring provider use of PCS terms.
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Section 99
medical/surgical and ancillary sections — Distinguish Radiation Therapy from Medical and Surgical device procedures.
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Section 100
seven-character PCS structure — Construct the PCS concepts for a laparoscopic total cholecystectomy.
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Section 101
root operation selection — Distinguish Replacement from other device-related root operations.
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Section 102
body part and approach — Use the most specific available body part when choosing Excision versus Resection.
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Section 103
device and qualifier — Select a device/qualifier value from documented prosthetic fixation.
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Section 104
multiple procedures — Report biopsy plus definitive treatment performed at the same site.
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Section 105
PCS guidelines — Code insertion and subsequent removal of a device during the same episode.
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Section 106
medical/surgical and ancillary sections — Select the correct PCS section for blood-product transfusion.
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medical/surgical and ancillary sections — Select the correct PCS section for blood-product transfusion. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 107
IPPS fundamentals — Explain core IPPS and MS-DRG payment mechanics.
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Section 108
root operation selection — Apply Reposition to fracture reduction with fixation.
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Section 109
body part and approach — Identify the body-part, device, and qualifier information needed for coronary bypass coding.
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body part and approach — Identify the body-part, device, and qualifier information needed for coronary bypass coding. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 110
device and qualifier — Apply the Diagnostic qualifier to biopsy procedures.
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device and qualifier — Apply the Diagnostic qualifier to biopsy procedures. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 111
MS-DRGs — Apply FY 2026 MS-DRG Grouper principles.
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Section 112
MCC/CC concepts — Apply CC/MCC concepts without allowing reimbursement to drive diagnosis reporting.
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Section 113
principal diagnosis/procedure impact — Connect principal diagnosis/procedure rules to inpatient grouping.
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Section 114
IPPS fundamentals — Apply core IPPS payment and grouping principles.
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Section 115
medical necessity/utilization concepts — Evaluate medical necessity and inpatient utilization review.
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Section 116
outpatient versus inpatient reimbursement distinctions — Distinguish outpatient observation from acute inpatient reimbursement.
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Section 117
MS-DRGs — Apply FY 2026 MS-DRG Grouper principles.
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MS-DRGs — Apply FY 2026 MS-DRG Grouper principles. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 118
MCC/CC concepts — Apply CC/MCC concepts without allowing reimbursement to drive diagnosis reporting.
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Section 119
principal diagnosis/procedure impact — Connect principal diagnosis/procedure rules to inpatient grouping.
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Section 120
IPPS fundamentals — Apply core IPPS payment and grouping principles.
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Section 121
medical necessity/utilization concepts — Evaluate medical necessity and inpatient utilization review.
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Section 122
outpatient versus inpatient reimbursement distinctions — Distinguish outpatient observation from acute inpatient reimbursement.
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outpatient versus inpatient reimbursement distinctions — Distinguish outpatient observation from acute inpatient reimbursement. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 123
MS-DRGs — Apply FY 2026 MS-DRG Grouper principles.
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Section 124
MCC/CC concepts — Apply CC/MCC concepts without allowing reimbursement to drive diagnosis reporting.
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Section 125
principal diagnosis/procedure impact — Connect principal diagnosis/procedure rules to inpatient grouping.
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Section 126
IPPS fundamentals — Apply core IPPS payment and grouping principles.
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Section 127
medical necessity/utilization concepts — Evaluate medical necessity and inpatient utilization review.
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Section 128
outpatient versus inpatient reimbursement distinctions — Distinguish outpatient observation from acute inpatient reimbursement.
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Section 129
MS-DRGs — Apply FY 2026 MS-DRG Grouper principles.
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MS-DRGs — Apply FY 2026 MS-DRG Grouper principles. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 130
MCC/CC concepts — Apply CC/MCC concepts without allowing reimbursement to drive diagnosis reporting.
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Section 131
principal diagnosis/procedure impact — Connect principal diagnosis/procedure rules to inpatient grouping.
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Section 132
IPPS fundamentals — Apply core IPPS payment and grouping principles.
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Section 133
medical necessity/utilization concepts — Evaluate medical necessity and inpatient utilization review.
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Section 134
outpatient versus inpatient reimbursement distinctions — Distinguish outpatient observation from acute inpatient reimbursement.
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Section 135
MS-DRGs — Apply FY 2026 MS-DRG Grouper principles.
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MS-DRGs — Apply FY 2026 MS-DRG Grouper principles. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 136
MCC/CC concepts — Apply CC/MCC concepts without allowing reimbursement to drive diagnosis reporting.
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Section 137
principal diagnosis/procedure impact — Connect principal diagnosis/procedure rules to inpatient grouping.
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Section 138
IPPS fundamentals — Apply core IPPS payment and grouping principles.
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Section 139
medical necessity/utilization concepts — Evaluate medical necessity and inpatient utilization review.
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Section 140
outpatient versus inpatient reimbursement distinctions — Distinguish outpatient observation from acute inpatient reimbursement.
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Section 141
MS-DRGs — Apply FY 2026 MS-DRG Grouper principles.
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MS-DRGs — Apply FY 2026 MS-DRG Grouper principles. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 142
MCC/CC concepts — Apply CC/MCC concepts without allowing reimbursement to drive diagnosis reporting.
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Section 143
principal diagnosis/procedure impact — Connect principal diagnosis/procedure rules to inpatient grouping.
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Section 144
IPPS fundamentals — Apply core IPPS payment and grouping principles.
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IPPS fundamentals — Apply core IPPS payment and grouping principles. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 145
medical necessity/utilization concepts — Evaluate medical necessity and inpatient utilization review.
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medical necessity/utilization concepts — Evaluate medical necessity and inpatient utilization review. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 146
outpatient versus inpatient reimbursement distinctions — Distinguish outpatient observation from acute inpatient reimbursement.
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Section 147
provider documentation requirements — Apply provider documentation requirements in an inpatient coding/compliance scenario.
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Section 148
queries — Apply queries in an inpatient coding/compliance scenario.
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queries — Apply queries in an inpatient coding/compliance scenario. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 149
coding compliance — Apply coding compliance in an inpatient coding/compliance scenario.
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Section 150
audits — Apply audits in an inpatient coding/compliance scenario.
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Section 151
clinical validation — Apply clinical validation in an inpatient coding/compliance scenario.
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Section 152
ethical coding — Apply ethical coding in an inpatient coding/compliance scenario.
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Section 153
provider documentation requirements — Apply provider documentation requirements in an inpatient coding/compliance scenario.
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Section 154
queries — Apply queries in an inpatient coding/compliance scenario.
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Section 155
coding compliance — Apply coding compliance in an inpatient coding/compliance scenario.
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Section 156
audits — Apply audits in an inpatient coding/compliance scenario.
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Section 157
clinical validation — Apply clinical validation in an inpatient coding/compliance scenario.
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Section 158
ethical coding — Apply ethical coding in an inpatient coding/compliance scenario.
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Section 159
provider documentation requirements — Apply provider documentation requirements in an inpatient coding/compliance scenario.
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Section 160
queries — Apply queries in an inpatient coding/compliance scenario.
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queries — Apply queries in an inpatient coding/compliance scenario. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 161
coding compliance — Apply coding compliance in an inpatient coding/compliance scenario.
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coding compliance — Apply coding compliance in an inpatient coding/compliance scenario. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 162
audits — Apply audits in an inpatient coding/compliance scenario.
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Section 163
clinical validation — Apply clinical validation in an inpatient coding/compliance scenario.
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clinical validation — Apply clinical validation in an inpatient coding/compliance scenario. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 164
ethical coding — Apply ethical coding in an inpatient coding/compliance scenario.
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Section 165
provider documentation requirements — Apply provider documentation requirements in an inpatient coding/compliance scenario.
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provider documentation requirements — Apply provider documentation requirements in an inpatient coding/compliance scenario. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 166
queries — Apply queries in an inpatient coding/compliance scenario.
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queries — Apply queries in an inpatient coding/compliance scenario. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 167
coding compliance — Apply coding compliance in an inpatient coding/compliance scenario.
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coding compliance — Apply coding compliance in an inpatient coding/compliance scenario. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 168
audits — Apply audits in an inpatient coding/compliance scenario.
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audits — Apply audits in an inpatient coding/compliance scenario. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 169
clinical validation — Apply clinical validation in an inpatient coding/compliance scenario.
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clinical validation — Apply clinical validation in an inpatient coding/compliance scenario. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 170
ethical coding — Apply ethical coding in an inpatient coding/compliance scenario.
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Section 171
anatomy — Apply anatomy in an inpatient coding context.
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anatomy — Apply anatomy in an inpatient coding context. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 172
medical terminology — Apply medical terminology in an inpatient coding context.
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Section 173
pharmacology relevant to inpatient records — Apply pharmacology relevant to inpatient records in an inpatient coding context.
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Section 174
diagnostic and procedural terminology — Apply diagnostic and procedural terminology in an inpatient coding context.
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Section 175
anatomy — Apply anatomy in an inpatient coding context.
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Section 176
medical terminology — Apply medical terminology in an inpatient coding context.
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Section 177
pharmacology relevant to inpatient records — Apply pharmacology relevant to inpatient records in an inpatient coding context.
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Section 178
diagnostic and procedural terminology — Apply diagnostic and procedural terminology in an inpatient coding context.
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diagnostic and procedural terminology — Apply diagnostic and procedural terminology in an inpatient coding context. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 179
anatomy — Apply anatomy in an inpatient coding context.
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anatomy — Apply anatomy in an inpatient coding context. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 180
medical terminology — Apply medical terminology in an inpatient coding context.
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Section 181
pharmacology relevant to inpatient records — Apply pharmacology relevant to inpatient records in an inpatient coding context.
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Section 182
diagnostic and procedural terminology — Apply diagnostic and procedural terminology in an inpatient coding context.
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diagnostic and procedural terminology — Apply diagnostic and procedural terminology in an inpatient coding context. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 183
anatomy — Apply anatomy in an inpatient coding context.
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anatomy — Apply anatomy in an inpatient coding context. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 184
medical terminology — Apply medical terminology in an inpatient coding context.
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Section 185
pharmacology relevant to inpatient records — Apply pharmacology relevant to inpatient records in an inpatient coding context.
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Section 186
diagnostic and procedural terminology — Apply diagnostic and procedural terminology in an inpatient coding context.
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Section 187
abstract diagnoses and procedures from inpatient record — Integrate abstract diagnoses and procedures from inpatient record across an inpatient case.
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Section 188
assign principal/secondary diagnoses — Integrate assign principal/secondary diagnoses across an inpatient case.
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Section 189
assign ICD-10-PCS codes — Integrate assign ICD-10-PCS codes across an inpatient case.
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Section 190
apply sequencing and reimbursement logic — Integrate apply sequencing and reimbursement logic across an inpatient case.
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Section 191
abstract diagnoses and procedures from inpatient record — Integrate abstract diagnoses and procedures from inpatient record across an inpatient case.
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Section 192
assign principal/secondary diagnoses — Integrate assign principal/secondary diagnoses across an inpatient case.
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Section 193
assign ICD-10-PCS codes — Integrate assign ICD-10-PCS codes across an inpatient case.
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Section 194
apply sequencing and reimbursement logic — Integrate apply sequencing and reimbursement logic across an inpatient case.
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Section 195
abstract diagnoses and procedures from inpatient record — Integrate abstract diagnoses and procedures from inpatient record across an inpatient case.
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Section 196
assign principal/secondary diagnoses — Integrate assign principal/secondary diagnoses across an inpatient case.
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Section 197
official inpatient diagnosis guidelines — Apply FY 2026 documentation rules for social determinants of health.
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Section 198
apply sequencing and reimbursement logic — Integrate apply sequencing and reimbursement logic across an inpatient case.
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Section 199
abstract diagnoses and procedures from inpatient record — Integrate abstract diagnoses and procedures from inpatient record across an inpatient case.
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abstract diagnoses and procedures from inpatient record — Integrate abstract diagnoses and procedures from inpatient record across an inpatient case. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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Section 200
assign principal/secondary diagnoses — Integrate assign principal/secondary diagnoses across an inpatient case.
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assign principal/secondary diagnoses — Integrate assign principal/secondary diagnoses across an inpatient case. unlocks with Pro.Unlock Pro to read the full 2 topics flashcard-note study guide for this section.
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