Certified Inpatient Coding (CIC) Practice Exam

Which of the following actions reflects fraud in healthcare coding practices?

1. Choosing a diagnosis based on coding simplicity

2. Inaccurate coding due to misunderstanding guidelines

3. Choosing the most complex condition for MS-DRG

4. Omitting procedure codes for better billing

The correct answer is: Choosing the most complex condition for MS-DRG

Choosing the most complex condition for MS-DRG reflects fraud in healthcare coding practices because it involves intentionally selecting a diagnosis that is more severe than the patient's actual condition with the goal of maximizing reimbursement. This practice distorts the true clinical picture, leading to inflated billing and misrepresentation of services rendered, which is unethical and illegal. In contrast, selecting a diagnosis for coding simplicity may indicate a lack of understanding or an attempt to streamline the process, but it does not inherently involve misleading behavior. Similarly, an inaccurate code due to misunderstanding guidelines can result from a lack of knowledge rather than deliberate intent. Omitting procedure codes to enhance billing may still display intentions to manipulate billing, but that action falls under a different type of unethical behavior than that of choosing the most complex condition for higher payment. The key element in identifying fraud is the intentional misrepresentation to achieve greater financial gain, which is clearly represented by the action of intentionally selecting a more severe MS-DRG diagnosis.