CCS Exam 2 questions with correct
answers
A 23-year-old female is admitted for vaginal bleeding following a miscarriage two weeks
prior to this admission. She is afebrile at this time and is treated with an aspiration
dilation and curettage. Products of conception are found. Which of the following should
be the principal diagnosis?
a. O03.1, Delayed or excessive hemorrhage following incomplete spontaneous abortion
b. O08.1, Delayed or excessive hemorrhage following ectopic and molar pregnancy
c. O03.6, Delayed or excessive hemorrhage following complete or unspecified
spontaneous abortion
d. O07.1, Delayed or excessive hemorrhage following failed attempted termination of
pregnancy - CORRECT ANSWERS-Correct Answer: A
A miscarriage is a spontaneous abortion. If the readmission is for the purpose of dealing
with retained products of conception, the spontaneous abortion is incomplete; use a
code from the O03 category (CMS 2020a, Section I.C.15.q., 68).
A 45-year-old woman underwent a carotid bypass and experienced a significant drop in
blood pressure during the surgery. The documentation suggested the patient may have
had a myocardial infarction. In accordance with coding guidelines, what should the
coding professional do?
a. Code complication of surgery NOS.
b. Query the physician to determine if the patient had hypotension.
c. Query the physician to determine if there was a complication of surgery.
d. Code preoperative shock. - CORRECT ANSWERS-Correct Answer: C
With the documented clinical indicators, it would be appropriate to query the physician
regarding the possibility of a complication resulting from surgery. When formulating a
query, it is unacceptable to lead a provider to document a particular response. The
query should not be directing or probing, and the provider should not be led to make an
assumption (AHIMA 2019c; CMS 2020a, Section I.B.16, 18).
,A 55-year-old patient with AIDS admitted after being struck by car while walking in a
parking lot. She has a comminuted, right femoral shaft fracture and a contusion of both
hands and right elbow abrasion. The principal diagnosis should be the:
a. AIDS
b. Fractured femur
c. Abrasion elbow
d. Contusion hand - CORRECT ANSWERS-Correct Answer: B
If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic
injury), the code for the unrelated condition (for example, the nature of injury code)
should be the principal diagnosis. The most severe injury should be sequenced first.
Other diagnoses would be B20 followed by additional diagnosis codes for all reported
HIV-related conditions (CMS 2020a, Section I.C.1.a.2.b., 21).
A 70-year-old patient was admitted with pneumonia. The history and physical
documented that the patient has a history of diabetes, hypertension, and migraine
headache about 10 years ago without recurrence. The patient was administered IV
antibiotics, metformin, and Altace during the hospitalization. What is the appropriate
reporting and sequencing of these diagnoses?
a. Diabetes, pneumonia, hypertension, and migraine headaches
b. Pneumonia, diabetes, hypertension, and history of migraine headaches
c. Pneumonia, diabetes, and hypertension
d. Hypertension, diabetes, and pneumonia - CORRECT ANSWERS-Correct Answer: C
Pneumonia, diabetes, hypertension should be coded with the principal diagnosis of
pneumonia since that was the reason for the admission. The migraine headaches are a
past condition and would not be coded as per the reporting guidelines for the UHDDS
for "other conditions" (CMS 2020a, Section III, 110-112).
A 78-year-old patient is admitted with shortness of breath and a chest x-ray reveals
infiltrates in the lung with pleural effusion. The patient also has a history of hypertension
with left ventricular hypertrophy. The patient is given Lasix and the shortness of breath
is relieved. From the information given, what is the probable principal diagnosis?
a. Pneumonia
b. Congestive heart failure
c. Pleural effusion
d. Chronic obstructive pulmonary disease - CORRECT ANSWERS-Correct Answer: B
The patient has underlying symptoms specific to CHF (hypertension/ventricular
hypertrophy) and Lasix was effective in relieving the SOB. Also, congestive heart failure
includes symptoms such as shortness of breath and pleural effusion. Taken together,
this indicates that congestive heart failure is the probable principal diagnosis (CMS
2020a, Section II, 107).
A coder assigns both 47562 and 47600 on the same patient's record. What coding edit
should be triggered?
a. Medical necessity
b. Medically unlikely
c. Sex/procedure edit
, d. Diagnosis/age edit - CORRECT ANSWERS-Correct Answer: B
These codes are both for cholecystectomy; one performed laparoscopically, one
performed via an open approach. This should trigger a medically unlikely edit since the
patient only has one gallbladder to remove, which would be done with one method or
another, but not both (Casto 2018, 256).
A coder is working from his work queue and gets assigned the outpatient surgery record
of the hospital administrator. Is this an ethical issue? Why or why not?
a. Yes, only the coding supervisor should code the record of the administrator
b. Yes, the coder should never work on a chart of another hospital employee
c. No, the coder can code the record as normal and look at previous encounters
d. No, the coder can assign codes for the encounter without an ethical concern -
CORRECT ANSWERS-Correct Answer: D
As long as the coder performs his work as he always does and only accesses the
information necessary to complete the chart, there is no ethical issue (AHIMA
Standards of Ethical Coding 2016).
A coding supervisor performs an internal audit on the coding staff. The overall accuracy
results are 85% and the expectation is 95%. She decides to eliminate the worst records
from the audit in order to bolster the score which then becomes 93% and will make her
look better to her boss. Is this ethically okay for her to do?
a. Yes, internal audit criteria are determined by the coding supervisor and can be
changed by her.
b. Yes, if her boss approves of the elimination of the records, then it fine and there is no
ethical issue.
c. No, only the HIM Director can make changes to the audit including the number of
records reviewed.
d. No, the audit criteria should not be altered to provide a better score or improve the
supervisor's status. - CORRECT ANSWERS-Correct Answer: D
Once determined, audit criteria, including the number of charts to be reviewed, should
not be altered. This skews the scores and will provide inaccurate information (AHIMA
Standards of Ethical Coding 2016).
A condition that is established after study to be chiefly responsible for the admission is
the:
a. Reason for visit
b. Principal procedure
c. A complication of outpatient care
d. Principal diagnosis - CORRECT ANSWERS-Correct Answer: D
The principal diagnosis is defined as the condition "established after study to be chiefly
responsible for occasioning the admission of the patient to the hospital for care."
Selecting the principal diagnosis depends on the circumstances of the admission and
why the patient was admitted (Schraffenberger and Palkie 2020, 92; CMS 2020a,
Section II, 107).
answers
A 23-year-old female is admitted for vaginal bleeding following a miscarriage two weeks
prior to this admission. She is afebrile at this time and is treated with an aspiration
dilation and curettage. Products of conception are found. Which of the following should
be the principal diagnosis?
a. O03.1, Delayed or excessive hemorrhage following incomplete spontaneous abortion
b. O08.1, Delayed or excessive hemorrhage following ectopic and molar pregnancy
c. O03.6, Delayed or excessive hemorrhage following complete or unspecified
spontaneous abortion
d. O07.1, Delayed or excessive hemorrhage following failed attempted termination of
pregnancy - CORRECT ANSWERS-Correct Answer: A
A miscarriage is a spontaneous abortion. If the readmission is for the purpose of dealing
with retained products of conception, the spontaneous abortion is incomplete; use a
code from the O03 category (CMS 2020a, Section I.C.15.q., 68).
A 45-year-old woman underwent a carotid bypass and experienced a significant drop in
blood pressure during the surgery. The documentation suggested the patient may have
had a myocardial infarction. In accordance with coding guidelines, what should the
coding professional do?
a. Code complication of surgery NOS.
b. Query the physician to determine if the patient had hypotension.
c. Query the physician to determine if there was a complication of surgery.
d. Code preoperative shock. - CORRECT ANSWERS-Correct Answer: C
With the documented clinical indicators, it would be appropriate to query the physician
regarding the possibility of a complication resulting from surgery. When formulating a
query, it is unacceptable to lead a provider to document a particular response. The
query should not be directing or probing, and the provider should not be led to make an
assumption (AHIMA 2019c; CMS 2020a, Section I.B.16, 18).
,A 55-year-old patient with AIDS admitted after being struck by car while walking in a
parking lot. She has a comminuted, right femoral shaft fracture and a contusion of both
hands and right elbow abrasion. The principal diagnosis should be the:
a. AIDS
b. Fractured femur
c. Abrasion elbow
d. Contusion hand - CORRECT ANSWERS-Correct Answer: B
If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic
injury), the code for the unrelated condition (for example, the nature of injury code)
should be the principal diagnosis. The most severe injury should be sequenced first.
Other diagnoses would be B20 followed by additional diagnosis codes for all reported
HIV-related conditions (CMS 2020a, Section I.C.1.a.2.b., 21).
A 70-year-old patient was admitted with pneumonia. The history and physical
documented that the patient has a history of diabetes, hypertension, and migraine
headache about 10 years ago without recurrence. The patient was administered IV
antibiotics, metformin, and Altace during the hospitalization. What is the appropriate
reporting and sequencing of these diagnoses?
a. Diabetes, pneumonia, hypertension, and migraine headaches
b. Pneumonia, diabetes, hypertension, and history of migraine headaches
c. Pneumonia, diabetes, and hypertension
d. Hypertension, diabetes, and pneumonia - CORRECT ANSWERS-Correct Answer: C
Pneumonia, diabetes, hypertension should be coded with the principal diagnosis of
pneumonia since that was the reason for the admission. The migraine headaches are a
past condition and would not be coded as per the reporting guidelines for the UHDDS
for "other conditions" (CMS 2020a, Section III, 110-112).
A 78-year-old patient is admitted with shortness of breath and a chest x-ray reveals
infiltrates in the lung with pleural effusion. The patient also has a history of hypertension
with left ventricular hypertrophy. The patient is given Lasix and the shortness of breath
is relieved. From the information given, what is the probable principal diagnosis?
a. Pneumonia
b. Congestive heart failure
c. Pleural effusion
d. Chronic obstructive pulmonary disease - CORRECT ANSWERS-Correct Answer: B
The patient has underlying symptoms specific to CHF (hypertension/ventricular
hypertrophy) and Lasix was effective in relieving the SOB. Also, congestive heart failure
includes symptoms such as shortness of breath and pleural effusion. Taken together,
this indicates that congestive heart failure is the probable principal diagnosis (CMS
2020a, Section II, 107).
A coder assigns both 47562 and 47600 on the same patient's record. What coding edit
should be triggered?
a. Medical necessity
b. Medically unlikely
c. Sex/procedure edit
, d. Diagnosis/age edit - CORRECT ANSWERS-Correct Answer: B
These codes are both for cholecystectomy; one performed laparoscopically, one
performed via an open approach. This should trigger a medically unlikely edit since the
patient only has one gallbladder to remove, which would be done with one method or
another, but not both (Casto 2018, 256).
A coder is working from his work queue and gets assigned the outpatient surgery record
of the hospital administrator. Is this an ethical issue? Why or why not?
a. Yes, only the coding supervisor should code the record of the administrator
b. Yes, the coder should never work on a chart of another hospital employee
c. No, the coder can code the record as normal and look at previous encounters
d. No, the coder can assign codes for the encounter without an ethical concern -
CORRECT ANSWERS-Correct Answer: D
As long as the coder performs his work as he always does and only accesses the
information necessary to complete the chart, there is no ethical issue (AHIMA
Standards of Ethical Coding 2016).
A coding supervisor performs an internal audit on the coding staff. The overall accuracy
results are 85% and the expectation is 95%. She decides to eliminate the worst records
from the audit in order to bolster the score which then becomes 93% and will make her
look better to her boss. Is this ethically okay for her to do?
a. Yes, internal audit criteria are determined by the coding supervisor and can be
changed by her.
b. Yes, if her boss approves of the elimination of the records, then it fine and there is no
ethical issue.
c. No, only the HIM Director can make changes to the audit including the number of
records reviewed.
d. No, the audit criteria should not be altered to provide a better score or improve the
supervisor's status. - CORRECT ANSWERS-Correct Answer: D
Once determined, audit criteria, including the number of charts to be reviewed, should
not be altered. This skews the scores and will provide inaccurate information (AHIMA
Standards of Ethical Coding 2016).
A condition that is established after study to be chiefly responsible for the admission is
the:
a. Reason for visit
b. Principal procedure
c. A complication of outpatient care
d. Principal diagnosis - CORRECT ANSWERS-Correct Answer: D
The principal diagnosis is defined as the condition "established after study to be chiefly
responsible for occasioning the admission of the patient to the hospital for care."
Selecting the principal diagnosis depends on the circumstances of the admission and
why the patient was admitted (Schraffenberger and Palkie 2020, 92; CMS 2020a,
Section II, 107).
