CCDS
Question 1.
A patient is admitted from the emergency department (ED) with a diagnosis of weakness and anemia. After admission and further
treatment with packed red blood cells (PRBC), GI consult, and endoscopy, the physician includes the following diagnoses in the
discharge summary: anemia, suspected bleeding gastric ulcer, and GERD. What would be the most appropriate principle diagnosis?
A. Bleeding gastric ulcer B. Anemia C. GERD D. Weakness
ANSWER
A. Bleeding gastric ulcer
Question 2.
A patient is admitted with new-onset seizures. Head CT reveals a mass in the occipital region. The physician documents possible
brain tumor, and the patient is transferred to another hospital for further workup. What would be the most appropriate principal
diagnosis based upon this documentation? A. Seizure B. Neoplasm of occipital region C. Head mass D. Head tumor
ANSWER
B. Neoplasm of occipital region
Question 3.
A hospital's base rate or blended rate is: 1. Calculated annually 2. Dependent upon indirect costs for graduate medical education and
new technology 3. Adjusted based upon number of low-income patients cared for 4. Not adjusted based upon capital expenses A. 1
and 2 B. 2 and 3 C. 1,2, and 3 D. 1,2,3, and 4
ANSWER
C. 1,2, and 3
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new technology
3. Adjusted based upon number of low-income patients cared for
Question 4.
The final MS-DRG assigned to a patient's medical record should: A. Reflect the amount of time the physician spent with the patient B.
Depend upon the patient's length of stay C. Be assigned by the physician D. Reflect the severity of illness (SOI) and resource
consumption of the patient's care
ANSWER
D. Reflect the severity of illness (SOI) and resource consumption of the patient 's care
Question 5.
A patient is admitted from the emergency department with the diagnosis of acute respiratory failure due to overdose of pain
medication and an aspiration pneumonia. What is the principal diagnosis? A. Acute respiratory failure B. Aspiration pneumonia C.
Poisoning D. Adverse effect of medication
ANSWER
C. Poisoning
, Question 6.
A patient is admitted with pneumonia, stage 1 chronic renal failure, chronic anemia, and COPD, While hospitalized the patient
receives IV antibiotics, inhalers, oxygen, IV fluids at 50mL/hr, and iron tablets. Keeping the guidelines for coding of secondary
diagnoses in mind, which condition should be coded? A. Pneumonia only B. Pneumonia and COPD only C. Pneumonia, COPD, and
anemia D. All of the conditions should be coded
ANSWER
D. All of the conditions should be coded
Question 7.
Which of the following is an example of a hospital-acquired condition? A. Fat embolism B. IV phlebitis C. Pneumonia D. Fractured
ulna
ANSWER
D. Fractured ulna
Question 8.
Which of the following is an example of documentation that would meet the present on admission criteria for coding? A. A diagnosis
that is indicated in the history and physical and ruled out in the discharge summary B. A diagnosis found in a previous medical record
C. A diagnosis that is listed as possible in the history and physical D. An acute condition identified on the third day of admission
ANSWER
C. A diagnosis that is listed as possible in the history and physical
Question 9.
A patient is admitted with abdominal pain and the history and physical indicated a diagnosis of probable colon cancer. On day two,
the physician documents acute renal failure in the progress notes and the patient receives IV fluids. The discharge summary lists
possible metastatic colon cancer and acute renal failure. The principal diagnosis would be: A. Colon cancer B. Acute renal failure C.
Abdominal pain D. Metastatic neoplasm of the colon
ANSWER
A. Colon cancer
Question 10.
Accurate documentation should: 1. Include identification of the patient's SOI 2. Identify conditions that are present on admission 3.
Support medical necessity A. 1 and 2 B. 2 and 3 C. 1 and 3 D. 1,2, and 3
ANSWER
D. 1,2, and 3
1. Include identification of the patient's SOI
2. Identify conditions that are present on admission
3. Support medical necessity
Question 11.
A patient with a history of metastatic lung cancer is directly admitted from the doctor's office with a diagnosis of anemia secondary to
chemotherapy. The patient receives two units of PRBCs and is discharged. What is the most appropriate principal diagnosis? A.
Respiratory neoplasm B. Anemia C. Admission for chemotherapy D. Admission for blood transfusion
ANSWER
B. Anemia
, Question 12.
A patient is admitted from the ED with rectal bleeding secondary to Coumadin toxicity. The physician documents that the patient had
a recent increase in Coumadin dosage due to low PT/PTT. The patient also has a history of COPD and CHF. What is the most
appropriate principal diagnosis? A. GI hemorrhage B. Coumadin toxicity C. COPD D. CHF
ANSWER
A. GI hemorrhage
Question 13.
A patient comes to the ED with fever, chills, and knee pain. Documentation states that the patient's admission is for knee prosthesis
removal due to infection. What is the principal diagnosis? (Do not include the procedure) A. Fever B. Sepsis C. Infected knee
prosthesis D. Knee pain
ANSWER
C. Infected knee prosthesis
Question 14.
A patient is admitted with pain in the lower extremity. The physician documents cellulitis due to septic joint. X-ray indicates possible
osteomyelitis. What is the principal diagnosis? A. Pain B. Cellulitis C. Osteomyelitis D. Septic joint
ANSWER
D. Septic joint
Question 15.
Which guideline provides the direction for the correct assignment of the principal diagnosis? A. Probable/possible conditions should
always be assigned over a symptom diagnosis B. Always code the most severe condition as principal C. The coder can link the
symptom to the most appropriate condition D. A sign and symptom code should only be used if no definitive diagnosis is determined
ANSWER
D. A sign and symptom code should only be used if no definitive diagnosis is determined.
Question 16.
A patient is admitted with hypertensive heart failure and chronic kidney disease (CKD). Appropriate code assignment would: A.
Identify individual codes for each condition B. Identify the most appropriate combination code C. Require a query for a link between
the conditions D. Utilize a combination code with the individual codes listed as secondary
ANSWER
D. Utilize a combination code with the individual codes listed as secondary
Question 17.
A patient is admitted with exacerbation of COPD, acute respiratory failure, and acute renal failure. Appropriate sequencing of the
conditions would be based upon: 1. Coding guidelines stating that if two conditions meet the criteria for principal diagnosis, either
condition can be sequenced first 2. Coding guidelines indicating chapter-specific guidelines 3. Understanding of the UDHHS definition
of a principal diagnosis A. 1 and 2 B. 2 and 3 C. 1 and 3 D. 1,2, and 3
ANSWER
D. 1,2, and 3
1. Coding guidelines stating that if two conditions meet the criteria for principal diagnosis, either condition can be sequenced first
2. Coding guidelines indicating chapter-specific guidelines
3. Understanding of the UDHHS definition of a principal diagnosis
Question 1.
A patient is admitted from the emergency department (ED) with a diagnosis of weakness and anemia. After admission and further
treatment with packed red blood cells (PRBC), GI consult, and endoscopy, the physician includes the following diagnoses in the
discharge summary: anemia, suspected bleeding gastric ulcer, and GERD. What would be the most appropriate principle diagnosis?
A. Bleeding gastric ulcer B. Anemia C. GERD D. Weakness
ANSWER
A. Bleeding gastric ulcer
Question 2.
A patient is admitted with new-onset seizures. Head CT reveals a mass in the occipital region. The physician documents possible
brain tumor, and the patient is transferred to another hospital for further workup. What would be the most appropriate principal
diagnosis based upon this documentation? A. Seizure B. Neoplasm of occipital region C. Head mass D. Head tumor
ANSWER
B. Neoplasm of occipital region
Question 3.
A hospital's base rate or blended rate is: 1. Calculated annually 2. Dependent upon indirect costs for graduate medical education and
new technology 3. Adjusted based upon number of low-income patients cared for 4. Not adjusted based upon capital expenses A. 1
and 2 B. 2 and 3 C. 1,2, and 3 D. 1,2,3, and 4
ANSWER
C. 1,2, and 3
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new technology
3. Adjusted based upon number of low-income patients cared for
Question 4.
The final MS-DRG assigned to a patient's medical record should: A. Reflect the amount of time the physician spent with the patient B.
Depend upon the patient's length of stay C. Be assigned by the physician D. Reflect the severity of illness (SOI) and resource
consumption of the patient's care
ANSWER
D. Reflect the severity of illness (SOI) and resource consumption of the patient 's care
Question 5.
A patient is admitted from the emergency department with the diagnosis of acute respiratory failure due to overdose of pain
medication and an aspiration pneumonia. What is the principal diagnosis? A. Acute respiratory failure B. Aspiration pneumonia C.
Poisoning D. Adverse effect of medication
ANSWER
C. Poisoning
, Question 6.
A patient is admitted with pneumonia, stage 1 chronic renal failure, chronic anemia, and COPD, While hospitalized the patient
receives IV antibiotics, inhalers, oxygen, IV fluids at 50mL/hr, and iron tablets. Keeping the guidelines for coding of secondary
diagnoses in mind, which condition should be coded? A. Pneumonia only B. Pneumonia and COPD only C. Pneumonia, COPD, and
anemia D. All of the conditions should be coded
ANSWER
D. All of the conditions should be coded
Question 7.
Which of the following is an example of a hospital-acquired condition? A. Fat embolism B. IV phlebitis C. Pneumonia D. Fractured
ulna
ANSWER
D. Fractured ulna
Question 8.
Which of the following is an example of documentation that would meet the present on admission criteria for coding? A. A diagnosis
that is indicated in the history and physical and ruled out in the discharge summary B. A diagnosis found in a previous medical record
C. A diagnosis that is listed as possible in the history and physical D. An acute condition identified on the third day of admission
ANSWER
C. A diagnosis that is listed as possible in the history and physical
Question 9.
A patient is admitted with abdominal pain and the history and physical indicated a diagnosis of probable colon cancer. On day two,
the physician documents acute renal failure in the progress notes and the patient receives IV fluids. The discharge summary lists
possible metastatic colon cancer and acute renal failure. The principal diagnosis would be: A. Colon cancer B. Acute renal failure C.
Abdominal pain D. Metastatic neoplasm of the colon
ANSWER
A. Colon cancer
Question 10.
Accurate documentation should: 1. Include identification of the patient's SOI 2. Identify conditions that are present on admission 3.
Support medical necessity A. 1 and 2 B. 2 and 3 C. 1 and 3 D. 1,2, and 3
ANSWER
D. 1,2, and 3
1. Include identification of the patient's SOI
2. Identify conditions that are present on admission
3. Support medical necessity
Question 11.
A patient with a history of metastatic lung cancer is directly admitted from the doctor's office with a diagnosis of anemia secondary to
chemotherapy. The patient receives two units of PRBCs and is discharged. What is the most appropriate principal diagnosis? A.
Respiratory neoplasm B. Anemia C. Admission for chemotherapy D. Admission for blood transfusion
ANSWER
B. Anemia
, Question 12.
A patient is admitted from the ED with rectal bleeding secondary to Coumadin toxicity. The physician documents that the patient had
a recent increase in Coumadin dosage due to low PT/PTT. The patient also has a history of COPD and CHF. What is the most
appropriate principal diagnosis? A. GI hemorrhage B. Coumadin toxicity C. COPD D. CHF
ANSWER
A. GI hemorrhage
Question 13.
A patient comes to the ED with fever, chills, and knee pain. Documentation states that the patient's admission is for knee prosthesis
removal due to infection. What is the principal diagnosis? (Do not include the procedure) A. Fever B. Sepsis C. Infected knee
prosthesis D. Knee pain
ANSWER
C. Infected knee prosthesis
Question 14.
A patient is admitted with pain in the lower extremity. The physician documents cellulitis due to septic joint. X-ray indicates possible
osteomyelitis. What is the principal diagnosis? A. Pain B. Cellulitis C. Osteomyelitis D. Septic joint
ANSWER
D. Septic joint
Question 15.
Which guideline provides the direction for the correct assignment of the principal diagnosis? A. Probable/possible conditions should
always be assigned over a symptom diagnosis B. Always code the most severe condition as principal C. The coder can link the
symptom to the most appropriate condition D. A sign and symptom code should only be used if no definitive diagnosis is determined
ANSWER
D. A sign and symptom code should only be used if no definitive diagnosis is determined.
Question 16.
A patient is admitted with hypertensive heart failure and chronic kidney disease (CKD). Appropriate code assignment would: A.
Identify individual codes for each condition B. Identify the most appropriate combination code C. Require a query for a link between
the conditions D. Utilize a combination code with the individual codes listed as secondary
ANSWER
D. Utilize a combination code with the individual codes listed as secondary
Question 17.
A patient is admitted with exacerbation of COPD, acute respiratory failure, and acute renal failure. Appropriate sequencing of the
conditions would be based upon: 1. Coding guidelines stating that if two conditions meet the criteria for principal diagnosis, either
condition can be sequenced first 2. Coding guidelines indicating chapter-specific guidelines 3. Understanding of the UDHHS definition
of a principal diagnosis A. 1 and 2 B. 2 and 3 C. 1 and 3 D. 1,2, and 3
ANSWER
D. 1,2, and 3
1. Coding guidelines stating that if two conditions meet the criteria for principal diagnosis, either condition can be sequenced first
2. Coding guidelines indicating chapter-specific guidelines
3. Understanding of the UDHHS definition of a principal diagnosis
