CERTIFIED CODING SPECIALIST 3
FLASHCARDS AND HIGH-YIELD CODING
TOPICS 2026
◉ A condition is present on admission when:
a. It is the principal diagnosis
b. It is accordance with medical staff bylaws
c. A condition that occurs prior to an inpatient admission
d. It is present within 3 days after admission. Answer: c. A condition
that occurs prior to an inpatient admission
**It is important to understand the time frame for assigning a status
code specifying that a condition is present on admission (Leon-
Chisen 2017, 571-574).
◉ A patient was admitted after a fall down the steps. The patient
was unconscious for approximately 45 minutes and was admitted to
the emergency department (ED) within 3 hours of the fall. A CT scan
was performed within an hour of admission to the ED. A cerebral
contusion was diagnosed by the ED physician based on the findings
in the CT scan. What conditions should be reported on the Uniform
Billing form 04 (UB-04)?
,R40.0 Somnolence
S02.91XA Unspecified fracture of skull, initial encounter for closed
fracture
S06.331A Contusion and laceration of cerebrum, unspecified, with
loss of consciousness of 30 minutes or less, initial encounter
S06.332A Contusion and laceration of cerebrum, unspecified, with
loss of consciousness of 31 minutes to 59 minutes, initial encounter
W10.9XXA Fall (on) (from) unspecified stairs and steps, initial
encounter
a. S02.91XA, W10.9XXA
b. R40.0
c. S06.331A, W10.9XXA
d. S06.332A, W10.9XXA. Answer: d. S06.332A:Contusion and
laceration of cerebrum, unspecified, with loss of consciousness of 31
minutes to 59 minutes, initial encounter.
W10.9XXA: Fall (on) (from) unspecified stairs and steps, initial
encounter
**The code for the injury to the brain also includes the time of
unconsciousness. The external cause code is provided here as part of
the review; however, no external cause codes are used on the exam
,except those for poisonings and adverse effects of drugs (Leon-
Chisen 2017, 487-488).
◉ Medicare reimbursement depends on all of the following, except:
a. The correct designation of the principal diagnosis
b. Policies and procedures of the medical staff
c. The presence or absence of additional codes that represent
complications, comorbidities, or major complications/comorbidities
d. Procedures performed. Answer: b. Policies and procedures of the
medical staff
**Policies and procedures of the medical staff are not relevant. But
the presence or absence of additional codes that represent
complications, comorbidities, or major complications/
comorbidities are all important to determine the MS-DRG as part of
Medicare Acute Inpatient Prospective Payment System (Leon-Chisen
2017, 566; Rinehart-Thompson 2016a, 240-241).
◉ A 35-year-old woman has hypertension with acute renal failure
and stage 3 chronic kidney disease. What code would be assigned?
a. N17.9, Acute kidney failure, unspecified
, b. I13.2, Hypertensive heart and chronic kidney disease with heart
failure and with stage 5 chronic kidney disease, or end stage renal
disease
c. I50.9, Heart failure, unspecified
d. N17.9, Acute kidney failure, unspecified and I12.9, Hypertensive
chronic kidney disease with stage 1 through stage 4 chronic kidney
disease, or unspecified chronic kidney disease and N18.3, Chronic
kidney disease, stage 3 (moderate). Answer: d. N17.9, Acute kidney
failure, unspecified and I12.9, Hypertensive chronic kidney disease
with stage 1 through stage 4 chronic kidney disease, or unspecified
chronic kidney disease and N18.3, Chronic kidney disease, stage 3
(moderate)
**Code the hypertension with stage 3 chronic kidney disease. In this
case, both hypertension and chronic kidney disease are documented
and a combination code is used. Also the code for the stage 3 chronic
kidney disease must be assigned due to the "code also" note. The
acute renal failure is identified with a separate code (HHS 2017,
Section I.C.9.a., 40; HHS 2017, Section I.C.14.a., 53).
◉ A patient is diagnosed with infertility due to endometriosis and
undergoes an outpatient laparoscopic laser destruction of pelvic
endometriosis. In order to code this encounter accurately, what
steps must the coder take?
a. Review the operative report to determine what procedure codes
to use and also to determine the site or sites of endometriosis so
FLASHCARDS AND HIGH-YIELD CODING
TOPICS 2026
◉ A condition is present on admission when:
a. It is the principal diagnosis
b. It is accordance with medical staff bylaws
c. A condition that occurs prior to an inpatient admission
d. It is present within 3 days after admission. Answer: c. A condition
that occurs prior to an inpatient admission
**It is important to understand the time frame for assigning a status
code specifying that a condition is present on admission (Leon-
Chisen 2017, 571-574).
◉ A patient was admitted after a fall down the steps. The patient
was unconscious for approximately 45 minutes and was admitted to
the emergency department (ED) within 3 hours of the fall. A CT scan
was performed within an hour of admission to the ED. A cerebral
contusion was diagnosed by the ED physician based on the findings
in the CT scan. What conditions should be reported on the Uniform
Billing form 04 (UB-04)?
,R40.0 Somnolence
S02.91XA Unspecified fracture of skull, initial encounter for closed
fracture
S06.331A Contusion and laceration of cerebrum, unspecified, with
loss of consciousness of 30 minutes or less, initial encounter
S06.332A Contusion and laceration of cerebrum, unspecified, with
loss of consciousness of 31 minutes to 59 minutes, initial encounter
W10.9XXA Fall (on) (from) unspecified stairs and steps, initial
encounter
a. S02.91XA, W10.9XXA
b. R40.0
c. S06.331A, W10.9XXA
d. S06.332A, W10.9XXA. Answer: d. S06.332A:Contusion and
laceration of cerebrum, unspecified, with loss of consciousness of 31
minutes to 59 minutes, initial encounter.
W10.9XXA: Fall (on) (from) unspecified stairs and steps, initial
encounter
**The code for the injury to the brain also includes the time of
unconsciousness. The external cause code is provided here as part of
the review; however, no external cause codes are used on the exam
,except those for poisonings and adverse effects of drugs (Leon-
Chisen 2017, 487-488).
◉ Medicare reimbursement depends on all of the following, except:
a. The correct designation of the principal diagnosis
b. Policies and procedures of the medical staff
c. The presence or absence of additional codes that represent
complications, comorbidities, or major complications/comorbidities
d. Procedures performed. Answer: b. Policies and procedures of the
medical staff
**Policies and procedures of the medical staff are not relevant. But
the presence or absence of additional codes that represent
complications, comorbidities, or major complications/
comorbidities are all important to determine the MS-DRG as part of
Medicare Acute Inpatient Prospective Payment System (Leon-Chisen
2017, 566; Rinehart-Thompson 2016a, 240-241).
◉ A 35-year-old woman has hypertension with acute renal failure
and stage 3 chronic kidney disease. What code would be assigned?
a. N17.9, Acute kidney failure, unspecified
, b. I13.2, Hypertensive heart and chronic kidney disease with heart
failure and with stage 5 chronic kidney disease, or end stage renal
disease
c. I50.9, Heart failure, unspecified
d. N17.9, Acute kidney failure, unspecified and I12.9, Hypertensive
chronic kidney disease with stage 1 through stage 4 chronic kidney
disease, or unspecified chronic kidney disease and N18.3, Chronic
kidney disease, stage 3 (moderate). Answer: d. N17.9, Acute kidney
failure, unspecified and I12.9, Hypertensive chronic kidney disease
with stage 1 through stage 4 chronic kidney disease, or unspecified
chronic kidney disease and N18.3, Chronic kidney disease, stage 3
(moderate)
**Code the hypertension with stage 3 chronic kidney disease. In this
case, both hypertension and chronic kidney disease are documented
and a combination code is used. Also the code for the stage 3 chronic
kidney disease must be assigned due to the "code also" note. The
acute renal failure is identified with a separate code (HHS 2017,
Section I.C.9.a., 40; HHS 2017, Section I.C.14.a., 53).
◉ A patient is diagnosed with infertility due to endometriosis and
undergoes an outpatient laparoscopic laser destruction of pelvic
endometriosis. In order to code this encounter accurately, what
steps must the coder take?
a. Review the operative report to determine what procedure codes
to use and also to determine the site or sites of endometriosis so
