CCS EXAM 2 QUESTIONS AND
VERIFIED ANSWERS
Which of the following data elements would a coding professional likely be responsible to abstract
from a patient's record?
a. Comorbidity
b. Race
c. Ethnicity
d. Admission date ✅✅ANSW-Correct Answer: A
While b, c, and d are data elements that are collected from each patient's record, they are generally
entered via an ADT system and not abstracted by a coding professional. Comorbid conditions are the
data elements that a coding professional would abstract from the record (Schraffenberger and Palkie
2020, 93).
What factors of the APR-DRG system allow for capturing the extent of the patient's conditions and
expected loss of life while an inpatient?
a. Severity of illness and risk of mortality
b. Severity of diagnosis and risk of morbidity
c. Complications and comorbidities
d. Hospital acquired conditions and present on admission ✅✅ANSW-Correct Answer: A
SOI and ROM are the factors that are used in the APR-DRG system to classify how ill a patient is and
whether they are expected to die while admitted (Foltz et al. 2016).
Which of the following diabetic conditions is considered an MCC?
a. Type II diabetes without complication
b. Type I diabetes without complication
c. Type I diabetes with ketoacidosis
d. Type II diabetes with polyneuropathy ✅✅ANSW-Correct Answer: C
The Type I diabetes with ketoacidosis is considered an MCC (Optum 360, 2019).
Which of the following injuries would you expect to see with an MCC designation?
a. Dislocation of jaw
,b. Laceration with foreign body of the neck
c. Fout-part humeral fracture of surgical neck
d. Blister of the right eyelid and periocular area ✅✅ANSW-Correct Answer: C
The fracture condition is the one with the MCC designation. None of the other conditions are MCCs
or even CCs (Optum 360, 2019).
A psychiatrist documents that a patient has wide mood swings ranging from excessive happiness to
loss of energy and crying. What condition could be suggested by the psychiatrist's documentation?
a. Bipolar disorder
b. Major depression
c. Anxiety
d. Psychosis ✅✅ANSW-Correct Answer: A
Recurring mood changes that result in periods of severe depression alternating with extreme elation
that are beyond the normal range of mood swings are called bipolar or circular disorders
(Schraffenberger and Palkie 2020, 216).
A patient record has documentation of esophageal varices. Which condition, if related, would affect
coding?
a. Arthritis
b. Liver disease
c. Chronic obstructive pulmonary disease
d. Erythema ✅✅ANSW-Correct Answer: B
Esophageal varices are often associated with cirrhosis of the liver. If documented, dual coding is
required with the underlying condition coded first (Schraffenberger and Palkie 2020, 370-372).
A patient is admitted with lethargy, congestive heart failure, and pleural effusion. The patient
underwent treatment with diuretics for the CHF, which has cleared. The pleural effusion required a
thoracentesis to determine the cause. At the time of discharge, the effusion was decreased but not
resolved. The correct coding assignment for this case would be:
a. Congestive heart failure
b. Pleural effusion
c. Congestive heart failure and pleural effusion
d. Lethargy, congestive heart failure, and pleural effusion ✅✅ANSW-Correct Answer: C
, Pleural effusion can be a symptom of CHF; however, in this case, it can be coded because it meets
the definition for coding additional diagnosis (it required a diagnostic procedure and it was still
unresolved at discharge) (CMS 2020a, Section III, 110-112). The sequencing of the two codes would
depend on the documentation and circumstances of the admission.
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 ✅✅ANSW-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 patient was admitted directly from his primary physician's office due to suspected avian influenza.
The admitting physician documentation indicated suspected avian influenza, along with signs and
symptoms of avian influenza. The patient left against medical advice (AMA) before confirmatory lab
tests could be drawn to identify the virus. The principal diagnosis should be coded from category:
a. J09, Influenza due to certain identified influenza viruses
b. J10, Influenza due to other identified influenza virus
c. J11, Influenza due to unidentified influenza virus
d. J12, Viral pneumonia, not elsewhere classified ✅✅ANSW-Correct Answer: C
"If the provider records "suspected" or "possible" or "probable" avian influenza, or novel influenza,
or other identified influenza, then the appropriate influenza code from category J11, Influenza due
to unidentified influenza virus, should be assigned. A code from category J09, Influenza due to
certain identified influenza viruses, should not be assigned nor should a code from category J10,
Influenza due to other identified influenza virus when the provider documents the influenza type as
"suspected," "probable," or "possible" (CMS 2020a, Section I, C.10.c, 53-54).
In CPT, if a patient has two lacerations of the arm that are repaired; one 1.6 cm and the other 3.5
cm. What additional information does the coder need to assign the correct repair code?
a. Specific location on the arm of each laceration
b. If tissue adhesive was utilized
VERIFIED ANSWERS
Which of the following data elements would a coding professional likely be responsible to abstract
from a patient's record?
a. Comorbidity
b. Race
c. Ethnicity
d. Admission date ✅✅ANSW-Correct Answer: A
While b, c, and d are data elements that are collected from each patient's record, they are generally
entered via an ADT system and not abstracted by a coding professional. Comorbid conditions are the
data elements that a coding professional would abstract from the record (Schraffenberger and Palkie
2020, 93).
What factors of the APR-DRG system allow for capturing the extent of the patient's conditions and
expected loss of life while an inpatient?
a. Severity of illness and risk of mortality
b. Severity of diagnosis and risk of morbidity
c. Complications and comorbidities
d. Hospital acquired conditions and present on admission ✅✅ANSW-Correct Answer: A
SOI and ROM are the factors that are used in the APR-DRG system to classify how ill a patient is and
whether they are expected to die while admitted (Foltz et al. 2016).
Which of the following diabetic conditions is considered an MCC?
a. Type II diabetes without complication
b. Type I diabetes without complication
c. Type I diabetes with ketoacidosis
d. Type II diabetes with polyneuropathy ✅✅ANSW-Correct Answer: C
The Type I diabetes with ketoacidosis is considered an MCC (Optum 360, 2019).
Which of the following injuries would you expect to see with an MCC designation?
a. Dislocation of jaw
,b. Laceration with foreign body of the neck
c. Fout-part humeral fracture of surgical neck
d. Blister of the right eyelid and periocular area ✅✅ANSW-Correct Answer: C
The fracture condition is the one with the MCC designation. None of the other conditions are MCCs
or even CCs (Optum 360, 2019).
A psychiatrist documents that a patient has wide mood swings ranging from excessive happiness to
loss of energy and crying. What condition could be suggested by the psychiatrist's documentation?
a. Bipolar disorder
b. Major depression
c. Anxiety
d. Psychosis ✅✅ANSW-Correct Answer: A
Recurring mood changes that result in periods of severe depression alternating with extreme elation
that are beyond the normal range of mood swings are called bipolar or circular disorders
(Schraffenberger and Palkie 2020, 216).
A patient record has documentation of esophageal varices. Which condition, if related, would affect
coding?
a. Arthritis
b. Liver disease
c. Chronic obstructive pulmonary disease
d. Erythema ✅✅ANSW-Correct Answer: B
Esophageal varices are often associated with cirrhosis of the liver. If documented, dual coding is
required with the underlying condition coded first (Schraffenberger and Palkie 2020, 370-372).
A patient is admitted with lethargy, congestive heart failure, and pleural effusion. The patient
underwent treatment with diuretics for the CHF, which has cleared. The pleural effusion required a
thoracentesis to determine the cause. At the time of discharge, the effusion was decreased but not
resolved. The correct coding assignment for this case would be:
a. Congestive heart failure
b. Pleural effusion
c. Congestive heart failure and pleural effusion
d. Lethargy, congestive heart failure, and pleural effusion ✅✅ANSW-Correct Answer: C
, Pleural effusion can be a symptom of CHF; however, in this case, it can be coded because it meets
the definition for coding additional diagnosis (it required a diagnostic procedure and it was still
unresolved at discharge) (CMS 2020a, Section III, 110-112). The sequencing of the two codes would
depend on the documentation and circumstances of the admission.
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 ✅✅ANSW-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 patient was admitted directly from his primary physician's office due to suspected avian influenza.
The admitting physician documentation indicated suspected avian influenza, along with signs and
symptoms of avian influenza. The patient left against medical advice (AMA) before confirmatory lab
tests could be drawn to identify the virus. The principal diagnosis should be coded from category:
a. J09, Influenza due to certain identified influenza viruses
b. J10, Influenza due to other identified influenza virus
c. J11, Influenza due to unidentified influenza virus
d. J12, Viral pneumonia, not elsewhere classified ✅✅ANSW-Correct Answer: C
"If the provider records "suspected" or "possible" or "probable" avian influenza, or novel influenza,
or other identified influenza, then the appropriate influenza code from category J11, Influenza due
to unidentified influenza virus, should be assigned. A code from category J09, Influenza due to
certain identified influenza viruses, should not be assigned nor should a code from category J10,
Influenza due to other identified influenza virus when the provider documents the influenza type as
"suspected," "probable," or "possible" (CMS 2020a, Section I, C.10.c, 53-54).
In CPT, if a patient has two lacerations of the arm that are repaired; one 1.6 cm and the other 3.5
cm. What additional information does the coder need to assign the correct repair code?
a. Specific location on the arm of each laceration
b. If tissue adhesive was utilized
