CCDS Practice Exam Questions And
Answers With 100% Verified
Rationales
A pt comes to the ED w/ fevers, chills, and knee pain. Documentation states that
the pt's admission is for knee prosthesis removal due to infection. What is the Pdx?
A. Fever
B. Sepsis
C. Infected knee prosthesis
D. Knee pain - ANSWER -C. Infected knee prosthesis
Rationale: Per guidelines, codes that describe s/s, as opposed to diagnoses, are
acceptable for reporting purposes when a related definitive dx has not been
established (confirmed) by the provider. In this example, sepsis is neither
documented nor supported by appropriate clinical indicators. And while the
documentation does include "fever, chills, and knee pain" the underlying cause is
the infected prosthesis. When a more definitive dx is available and treatment for
that dx is provided, the more specific code should be used. CDI may seek to find
out additional info on the underlying cause of the infection as well as to determine
if any complications of care exist. See Section I.B.16.
A pt is admitted w/ pain in a lower extremity. The physician documents cellulitis
d/t septic joint. X-ray indicates possible osteomyelitis. What is the Pdx?
A. Pain
B. Cellulitis
C. Osteomyelitis
D. Septic joint - ANSWER -D. Septic joint
Rationale: Documentation by the provider clearly indicates a septic joint. Only the
x-ray identifies possible osteomyelitis. A radiologist is not considered a treating
provider of care, and therefore the osteomyelitis cannot be coded. A query would
be necessary to ensure this documentation is generated as appropriate.
,Which of the following represents correct guidance for assigning a Pdx?
A. Probable/possible conditions should always be assigned over a symptoms
diagnosis
B. The most severe condition should always be coded as principal
C. The coder can link the symptoms to the most appropriate condition
D. A s/s code should only be used if no definitive dx is determined - ANSWER -D.
A s/s code should only be used if no definitive dx is determined.
Rationale: Per guidelines, "codes that describe s/s, as opposed to diagnoses, are
acceptable for reporting purposes when a related definitive dx has not been
established (confirmed) by the provider".
A pt is admitted with HTN heart failure and CKD. Appropriate code assignment
would:
A. Identify individual codes for each condition
B. Identify the most appropriate combo code
C. Require a query for a link between the conditions
D. Use a combo code w/ the individual codes listed as secondary - ANSWER -B.
Identify most appropriate combo code
Rationale: Combo code is a single code used to classify 2 diagnoses, a diagnosis w/
an associated 2nd process (manifestation), or a dx w/ an associated complication.
Assign only the combo code when that code fully identifies the dx conditions
involved or when Index so directs. Multiple coding should not be used when the
classification provides a combo code that clearly identifies all of the elements
documented in the dx. When the combo code lacks necessary specificity in
describing the manifestation or complication, an additional code should be used as
a secondary code.
Pt is admitted w/ an acute MI, acute respiratory failure, and a h/o of type 2 MI two
years previously. Appropriate sequencing of the conditions would be based on:
A. Coding guidelines stating that if 2 conditions meet the criteria for Pdx, the 1st
dx documented is sequenced 1st and the 2nd condition documented is sequenced
2nd
,B. Coding convention instruction to "code first" the etiology
C. The understanding that the condition requiring the most resource consumption
would be the Pdx
D. Coding guidelines stating that if 2 or more dx equally meet the definition for
Pdx based on circumstances of admit, Alphabetic Index, and Tabular List, either dx
may be sequenced first - ANSWER -D. Coding guidelines stating that if 2 or more
dx equally meet the definition for Pdx based on circumstances of admit, Alphabetic
Index, and Tabular List, either dx may be sequenced first
Rationale: Selection of Pdx will be based on circumstances of the admission. If
both respiratory failure and other acute condition are equally responsible for
occasioning the admission to the hospital and there are no chapter-specific
sequencing rules, either may be sequenced 1st.
Which of the following is true regarding the coding and reporting of HIV?
A. ICD-10 code B20 should be sequenced as Pdx in all cases
B. HIV status must be confirmed by a blood test
C. ICD-10 code B20, if sequenced as 2nd dx, qualifies as MCC
D. Coding depends on reason for admission - ANSWER -D. Coding depends on
reason for admission
Rationale: (a) Pt admitted for HIV-related condition...Pdx should be B20 followed
by additional dx codes for all reported HIV-related conditions (b) Pt w/ HIV
admitted for unrelated condition...the code for the unrelated condition should be
Pdx
Appropriate sequencing for a pt with UTI, PNA, sepsis, all POA, recognizes that:
A. The systemic infection is always sequenced as Pdx
B. The systemic infection is always sequenced as 2nd dx
C. The ICD-10 code for SIRS should be sequenced as Pdx
D. Documented organ failure is necessary before one can code sepsis - ANSWER -
A. Systemic infection is always sequenced as Pdx
Rationale: If reason for admit is both sepsis or severe sepsis and a localized
infection, such as PNA or cellulitis, a code (s) for the underlying systemic infection
, should be assigned first and the code for the localized infection should be assigned
as a 2nd dx. If the pt is admitted w/ localized infection, such as PNA and
sepsis/severe sepsis doesn't develop until after admit, the localized infection should
be assigned first, followed by the appropriate sepsis/severe sepsis codes.
A pt is admitted w/ back pain 2nd metastases of the spine. During the
hospitalizatio, the pt undergoes a bone scan and the physician documents new bone
mets of the spine. An oncology consult is completed, and RT is recommended. The
pt refuses further care, receives pain control for back pain and d/c to hospice. What
is the Pdx?
A. Metastatic colon ca
B. Pain
C. Bone mets
D. Palliative care - ANSWER -C. Bone mets
Rationale: Per guidelines, when a pt is admitted because of a primary neoplasm w/
mets and treatment is directed toward the 2nd site only, the 2nd neoplasm is
designated as the Pdx even though the primary malignancy is still present. Note
that pt refusal of tx does not preclude the condition from being reported or coded.
When coding a medical record that includes DM and manifestations of DM, the
specificity of DM coding depends on documentation of:
A. Acuity of DM
B. Whether the DM is controlled
C. Age of pt at time of dx
D. Any manifestations of the DM - ANSWER -D. Any manifestations of the DM
Rationale: Per guidelines, the DM codes are combo codes that include type of DM,
body system affected and the complications affecting that body system. As many
codes within a particular category as are necessary to describe all of the
complications of the disease may be used. They should be sequenced based on
reason for a particular encounter.
A late effect or sequela of a condition is defined as a condition that:
A. Always occurs
Answers With 100% Verified
Rationales
A pt comes to the ED w/ fevers, chills, and knee pain. Documentation states that
the pt's admission is for knee prosthesis removal due to infection. What is the Pdx?
A. Fever
B. Sepsis
C. Infected knee prosthesis
D. Knee pain - ANSWER -C. Infected knee prosthesis
Rationale: Per guidelines, codes that describe s/s, as opposed to diagnoses, are
acceptable for reporting purposes when a related definitive dx has not been
established (confirmed) by the provider. In this example, sepsis is neither
documented nor supported by appropriate clinical indicators. And while the
documentation does include "fever, chills, and knee pain" the underlying cause is
the infected prosthesis. When a more definitive dx is available and treatment for
that dx is provided, the more specific code should be used. CDI may seek to find
out additional info on the underlying cause of the infection as well as to determine
if any complications of care exist. See Section I.B.16.
A pt is admitted w/ pain in a lower extremity. The physician documents cellulitis
d/t septic joint. X-ray indicates possible osteomyelitis. What is the Pdx?
A. Pain
B. Cellulitis
C. Osteomyelitis
D. Septic joint - ANSWER -D. Septic joint
Rationale: Documentation by the provider clearly indicates a septic joint. Only the
x-ray identifies possible osteomyelitis. A radiologist is not considered a treating
provider of care, and therefore the osteomyelitis cannot be coded. A query would
be necessary to ensure this documentation is generated as appropriate.
,Which of the following represents correct guidance for assigning a Pdx?
A. Probable/possible conditions should always be assigned over a symptoms
diagnosis
B. The most severe condition should always be coded as principal
C. The coder can link the symptoms to the most appropriate condition
D. A s/s code should only be used if no definitive dx is determined - ANSWER -D.
A s/s code should only be used if no definitive dx is determined.
Rationale: Per guidelines, "codes that describe s/s, as opposed to diagnoses, are
acceptable for reporting purposes when a related definitive dx has not been
established (confirmed) by the provider".
A pt is admitted with HTN heart failure and CKD. Appropriate code assignment
would:
A. Identify individual codes for each condition
B. Identify the most appropriate combo code
C. Require a query for a link between the conditions
D. Use a combo code w/ the individual codes listed as secondary - ANSWER -B.
Identify most appropriate combo code
Rationale: Combo code is a single code used to classify 2 diagnoses, a diagnosis w/
an associated 2nd process (manifestation), or a dx w/ an associated complication.
Assign only the combo code when that code fully identifies the dx conditions
involved or when Index so directs. Multiple coding should not be used when the
classification provides a combo code that clearly identifies all of the elements
documented in the dx. When the combo code lacks necessary specificity in
describing the manifestation or complication, an additional code should be used as
a secondary code.
Pt is admitted w/ an acute MI, acute respiratory failure, and a h/o of type 2 MI two
years previously. Appropriate sequencing of the conditions would be based on:
A. Coding guidelines stating that if 2 conditions meet the criteria for Pdx, the 1st
dx documented is sequenced 1st and the 2nd condition documented is sequenced
2nd
,B. Coding convention instruction to "code first" the etiology
C. The understanding that the condition requiring the most resource consumption
would be the Pdx
D. Coding guidelines stating that if 2 or more dx equally meet the definition for
Pdx based on circumstances of admit, Alphabetic Index, and Tabular List, either dx
may be sequenced first - ANSWER -D. Coding guidelines stating that if 2 or more
dx equally meet the definition for Pdx based on circumstances of admit, Alphabetic
Index, and Tabular List, either dx may be sequenced first
Rationale: Selection of Pdx will be based on circumstances of the admission. If
both respiratory failure and other acute condition are equally responsible for
occasioning the admission to the hospital and there are no chapter-specific
sequencing rules, either may be sequenced 1st.
Which of the following is true regarding the coding and reporting of HIV?
A. ICD-10 code B20 should be sequenced as Pdx in all cases
B. HIV status must be confirmed by a blood test
C. ICD-10 code B20, if sequenced as 2nd dx, qualifies as MCC
D. Coding depends on reason for admission - ANSWER -D. Coding depends on
reason for admission
Rationale: (a) Pt admitted for HIV-related condition...Pdx should be B20 followed
by additional dx codes for all reported HIV-related conditions (b) Pt w/ HIV
admitted for unrelated condition...the code for the unrelated condition should be
Pdx
Appropriate sequencing for a pt with UTI, PNA, sepsis, all POA, recognizes that:
A. The systemic infection is always sequenced as Pdx
B. The systemic infection is always sequenced as 2nd dx
C. The ICD-10 code for SIRS should be sequenced as Pdx
D. Documented organ failure is necessary before one can code sepsis - ANSWER -
A. Systemic infection is always sequenced as Pdx
Rationale: If reason for admit is both sepsis or severe sepsis and a localized
infection, such as PNA or cellulitis, a code (s) for the underlying systemic infection
, should be assigned first and the code for the localized infection should be assigned
as a 2nd dx. If the pt is admitted w/ localized infection, such as PNA and
sepsis/severe sepsis doesn't develop until after admit, the localized infection should
be assigned first, followed by the appropriate sepsis/severe sepsis codes.
A pt is admitted w/ back pain 2nd metastases of the spine. During the
hospitalizatio, the pt undergoes a bone scan and the physician documents new bone
mets of the spine. An oncology consult is completed, and RT is recommended. The
pt refuses further care, receives pain control for back pain and d/c to hospice. What
is the Pdx?
A. Metastatic colon ca
B. Pain
C. Bone mets
D. Palliative care - ANSWER -C. Bone mets
Rationale: Per guidelines, when a pt is admitted because of a primary neoplasm w/
mets and treatment is directed toward the 2nd site only, the 2nd neoplasm is
designated as the Pdx even though the primary malignancy is still present. Note
that pt refusal of tx does not preclude the condition from being reported or coded.
When coding a medical record that includes DM and manifestations of DM, the
specificity of DM coding depends on documentation of:
A. Acuity of DM
B. Whether the DM is controlled
C. Age of pt at time of dx
D. Any manifestations of the DM - ANSWER -D. Any manifestations of the DM
Rationale: Per guidelines, the DM codes are combo codes that include type of DM,
body system affected and the complications affecting that body system. As many
codes within a particular category as are necessary to describe all of the
complications of the disease may be used. They should be sequenced based on
reason for a particular encounter.
A late effect or sequela of a condition is defined as a condition that:
A. Always occurs
