CCS PRACTICE 1 AND 2 CERTIFICATION
EVALUATION EXAMS 2026 SOLVED
QUESTIONS WITH FULL SOLUTION
◉ Codeable Documentation.
Answer: Provider documentation that is complete, legible, dated,
authenticated, and internally consistent.
◉ Authentication.
Answer: Provider's confirmation of authorship through a signature
or signature stamp.
◉ Principal Diagnosis (PDx).
Answer: Condition established after study chiefly responsible for
occasioning hospital admission.
◉ First-Listed Diagnosis.
Answer: The outpatient equivalent of the principal diagnosis; main
reason for the visit.
◉ Principal Procedure.
,Answer: Procedure performed for definitive treatment most related
to the principal diagnosis.
◉ Secondary Diagnoses.
Answer: Additional conditions coexisting or affecting treatment
during a hospital stay.
◉ Abstracting.
Answer: Reading the entire record to identify all reportable
diagnoses and procedures.
◉ Physician Query.
Answer: Non-leading communication seeking clarification for
ambiguous, conflicting, or incomplete documentation.
◉ Encoder.
Answer: Software that assists code lookup, edits, and grouping but
requires coder judgment.
◉ MS-DRG.
Answer: Logic assigning inpatient stays to payment groups based on
diagnoses and severity.
,◉ ICD-10-CM.
Answer: Diagnosis code set used in all U.S. care settings.
◉ ICD-10-PCS.
Answer: Seven-character procedure code set used for hospital
inpatient procedures only.
◉ CPT.
Answer: AMA-maintained code set for physician and outpatient
procedures and services.
◉ HCPCS Level II.
Answer: CMS-maintained alphanumeric code set for supplies, drugs,
and durable medical equipment.
◉ Combining Form.
Answer: A word root plus a combining vowel used to join word
parts.
◉ Etiology.
Answer: The cause or origin of a disease.
◉ Non-physician Documentation Exception: BMI.
, Answer: BMI may be coded from non-physician notes if the provider
documents the diagnosis.
◉ Non-physician Documentation Exception: Ulcer Stage.
Answer: Pressure ulcer stage may be coded from nursing notes if the
provider documents the ulcer.
◉ Non-physician Documentation Exception: Coma Scale.
Answer: Coma scale scores may be taken from non-physician
clinician documentation.
◉ Inpatient Uncertain Diagnosis Rule.
Answer: Probable or suspected conditions may be coded as
confirmed at discharge.
◉ Outpatient Uncertain Diagnosis Rule.
Answer: Probable or suspected conditions are never coded as
confirmed; code signs or symptoms.
◉ DAMP IT: D.
Answer: Degenerative (wear-and-tear) disease processes.
◉ DAMP IT: A.
EVALUATION EXAMS 2026 SOLVED
QUESTIONS WITH FULL SOLUTION
◉ Codeable Documentation.
Answer: Provider documentation that is complete, legible, dated,
authenticated, and internally consistent.
◉ Authentication.
Answer: Provider's confirmation of authorship through a signature
or signature stamp.
◉ Principal Diagnosis (PDx).
Answer: Condition established after study chiefly responsible for
occasioning hospital admission.
◉ First-Listed Diagnosis.
Answer: The outpatient equivalent of the principal diagnosis; main
reason for the visit.
◉ Principal Procedure.
,Answer: Procedure performed for definitive treatment most related
to the principal diagnosis.
◉ Secondary Diagnoses.
Answer: Additional conditions coexisting or affecting treatment
during a hospital stay.
◉ Abstracting.
Answer: Reading the entire record to identify all reportable
diagnoses and procedures.
◉ Physician Query.
Answer: Non-leading communication seeking clarification for
ambiguous, conflicting, or incomplete documentation.
◉ Encoder.
Answer: Software that assists code lookup, edits, and grouping but
requires coder judgment.
◉ MS-DRG.
Answer: Logic assigning inpatient stays to payment groups based on
diagnoses and severity.
,◉ ICD-10-CM.
Answer: Diagnosis code set used in all U.S. care settings.
◉ ICD-10-PCS.
Answer: Seven-character procedure code set used for hospital
inpatient procedures only.
◉ CPT.
Answer: AMA-maintained code set for physician and outpatient
procedures and services.
◉ HCPCS Level II.
Answer: CMS-maintained alphanumeric code set for supplies, drugs,
and durable medical equipment.
◉ Combining Form.
Answer: A word root plus a combining vowel used to join word
parts.
◉ Etiology.
Answer: The cause or origin of a disease.
◉ Non-physician Documentation Exception: BMI.
, Answer: BMI may be coded from non-physician notes if the provider
documents the diagnosis.
◉ Non-physician Documentation Exception: Ulcer Stage.
Answer: Pressure ulcer stage may be coded from nursing notes if the
provider documents the ulcer.
◉ Non-physician Documentation Exception: Coma Scale.
Answer: Coma scale scores may be taken from non-physician
clinician documentation.
◉ Inpatient Uncertain Diagnosis Rule.
Answer: Probable or suspected conditions may be coded as
confirmed at discharge.
◉ Outpatient Uncertain Diagnosis Rule.
Answer: Probable or suspected conditions are never coded as
confirmed; code signs or symptoms.
◉ DAMP IT: D.
Answer: Degenerative (wear-and-tear) disease processes.
◉ DAMP IT: A.
