CCS Prep Questions With Complete Solutions
A 16-year-old male was treated at your facility for a closed head
injury. The patient's 18-year-old wife accompanied him to the
hospital and signed the consent for admission and treatment
because of the patient's incapacity at the time. The patient has
requested that copies of his medical records must be sent to his
attorney. Who should sign the authorization to release the
records? Correct Answer The patient
A 64-year old female is admitted to the hospital with nausea,
vomiting, and edema. The patient has a history of diabetes and
takes Metformin and Lisinopril as prescribed. Blood sugar and
blood pressure are monitored while admitted. On the discharge
summary, the final diagnoses of acute renal failure and diabetes
are documented. What is the query opportunity for this record?
Correct Answer Does the patient have hypertension?
A coding professional reviews a health record and determines
that a code Medicare has designated as "unacceptable principal
diagnosis" is the correct code to assign. What should the coding
professional do? Correct Answer Assign the code even though
the insurer may not pay the claim
A completed and signed operative report needs clarification of
the size of the skin lesions that were removed. What process is
used for that clarification? Correct Answer Amendment
A HIM Department Budget Report for May shows a payroll
budget of $25,000 and an actual payroll expense of $22,345.
, The percent of budget variance for the month is: Correct
Answer 11%
A number of key elements for your facility's computerized
patient records are still input by clerical staff from handwritten
data entry sheets. You are concerned about the transfer of data.
If the vital signs stored in the database are not what were
originally recorded, the impact on patient care could be severe.
You are concerned about the: Correct Answer Validity of the
data
A patient has presented for back surgery with a diagnosis of
lumbar stenosis. Documentation notes the patient has leg pain,
tingling, and cramping as a result of the stenosis. In the patient's
final diagnosis, the surgeon notes only lumbar stenosis. What
other diagnosis appears to be missing from this statement based
on the information provided? Correct Answer Neuropathy
A patient is admitted to the hospital with a high fever, chills,
tachycardia, and a respiration rate of 26. Lactic acidosis is noted
in the labs. Pneumonia is diagnosed and the patient admitted to
ICU where antibiotics are given along with Levophed to help
maintain the patient's blood pressure which was in the extremely
low range. The patient's breathing was erratic and mechanical
ventilation was initiated. With a final diagnosis of pneumonia,
what is the query opportunity for this record? Correct Answer
Is this septic shock?
A patient is admitted to the hospital with shortness of breath and
congestive heart failure and subsequently develops respiratory
failure. The patient undergoes intubation with ventilator
A 16-year-old male was treated at your facility for a closed head
injury. The patient's 18-year-old wife accompanied him to the
hospital and signed the consent for admission and treatment
because of the patient's incapacity at the time. The patient has
requested that copies of his medical records must be sent to his
attorney. Who should sign the authorization to release the
records? Correct Answer The patient
A 64-year old female is admitted to the hospital with nausea,
vomiting, and edema. The patient has a history of diabetes and
takes Metformin and Lisinopril as prescribed. Blood sugar and
blood pressure are monitored while admitted. On the discharge
summary, the final diagnoses of acute renal failure and diabetes
are documented. What is the query opportunity for this record?
Correct Answer Does the patient have hypertension?
A coding professional reviews a health record and determines
that a code Medicare has designated as "unacceptable principal
diagnosis" is the correct code to assign. What should the coding
professional do? Correct Answer Assign the code even though
the insurer may not pay the claim
A completed and signed operative report needs clarification of
the size of the skin lesions that were removed. What process is
used for that clarification? Correct Answer Amendment
A HIM Department Budget Report for May shows a payroll
budget of $25,000 and an actual payroll expense of $22,345.
, The percent of budget variance for the month is: Correct
Answer 11%
A number of key elements for your facility's computerized
patient records are still input by clerical staff from handwritten
data entry sheets. You are concerned about the transfer of data.
If the vital signs stored in the database are not what were
originally recorded, the impact on patient care could be severe.
You are concerned about the: Correct Answer Validity of the
data
A patient has presented for back surgery with a diagnosis of
lumbar stenosis. Documentation notes the patient has leg pain,
tingling, and cramping as a result of the stenosis. In the patient's
final diagnosis, the surgeon notes only lumbar stenosis. What
other diagnosis appears to be missing from this statement based
on the information provided? Correct Answer Neuropathy
A patient is admitted to the hospital with a high fever, chills,
tachycardia, and a respiration rate of 26. Lactic acidosis is noted
in the labs. Pneumonia is diagnosed and the patient admitted to
ICU where antibiotics are given along with Levophed to help
maintain the patient's blood pressure which was in the extremely
low range. The patient's breathing was erratic and mechanical
ventilation was initiated. With a final diagnosis of pneumonia,
what is the query opportunity for this record? Correct Answer
Is this septic shock?
A patient is admitted to the hospital with shortness of breath and
congestive heart failure and subsequently develops respiratory
failure. The patient undergoes intubation with ventilator
