CCS PRACTICE REVIEW 2026 COMPLETE
VERIFIED SOLUTIONS
◍ A psychiatrist documents that a patient has wide mood swings from
excessive happiness to loss of energy and crying. What condition is
suspected?
a. Bipolar disorder
b. Major depression
c. Anxiety
d. Psychosis. Answer: A. Bipolar disorder
◍ A patient with a cephalic presentation anticipating a vaginal
delivery failed to progress. After measurement of the fetal head and a
trial of oxytocin, the patient underwent a cesarean section. What
condition should the coder suspect and query the physician about?
a. Twin pregnancy
b. Early delivery
c. Eclampsia
d. Cephalopelvic disproportion. Answer: d. Cephalopelvic
disproportion
◍ 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
coder 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.. Answer: c. Query the physician to
determine if there was a complication of surgery.
◍ If a patient's discharge summary does not contain a diagnosis that
is documented by the anesthesiologist in a preoperative evaluation
and that would impact MS-DRG assignment, the coder should:
a. Code only from the discharge diagnosis
b. Code the diagnosis reflected on the anesthesia preoperative
evaluation
c. Code the most severe symptom
d. Query the attending physician regarding the clinical significance of
that diagnosis. Answer: d. Query the attending physician regarding the
clinical significance of that diagnosis
◍ A patient has documentation of esophageal varices. What condition
may be related that may affect the coding?
a. Arthritis
b. Liver disease
c. Chronic obstructive pulmonary disease
d. Erythema. Answer: b. Liver disease
,◍ A patient admitted with acute abdominal pain, is fount to have
appendicitis, and has an appendectomy. The patient has a length of
stay for 2 days. What type of patient encounter is this?
a. Impatient
b. Outpatient
c. Long term care
d. Rehabilitation. Answer: a. Inpatient
◍ A patient was treated in the emergency department for a swollen
knee and an aspiration of the joint was performed. The patient was
then discharged home. It is important to make sure that which of the
following are documented and captured for billing purposes?
a. X-ray and other types of radiology examination
b. Procedures performed including the aspiration of the joint
c. Examination and management in the emergency department
d. All services provided including diagnostic and treatment
procedures, as well as physician services. Answer: d. All services
provided including diagnostic and treatment procedures, as well as
physician services.
◍ A patient has documentation on the discharge summary of
urosepsis. The coding staff queries the attending physician about the
condition and is provided further information that the patient has
septicemia. This is in alignment with the laboratory test and
medication given but the diagnosis of septicemia was not documented
by the physician. How should the physician be requested to document
the septicemia?
, a. A brand new history and physical should be dictated to replace the
one in the record.
b. An addendum to the chart should be written.
c. The new information should be squeezed in between lines within
the progress notes of the last day.
d. The query sheet will be sufficient to document this information..
Answer: b. An addendum to the chart should be written.
◍ The committee responsible for medical record completion reports
to which medical staff committee?
a. Chief executive officer of the facility
b. Medical Executive Committee
c. Discharge Planning Committee
d. Chief nursing officer. Answer: b. Medical Executive Committee
◍ Two areas of documentation in the medial record that are
significant areas of focus of accrediting agencies are:
a. Incident reports notion in the medical record and attorney's notes
b. Past medical reports and social worker notes
c. Timeliness and legibility of medical documents
d. Patient documentation and pastoral counseling. Answer: c.
Timeliness and legibility of medical documents
◍ In teaching facilities where electronic signatures are used for
residents and attending physicians:
a. Attending signature is all that is needed
VERIFIED SOLUTIONS
◍ A psychiatrist documents that a patient has wide mood swings from
excessive happiness to loss of energy and crying. What condition is
suspected?
a. Bipolar disorder
b. Major depression
c. Anxiety
d. Psychosis. Answer: A. Bipolar disorder
◍ A patient with a cephalic presentation anticipating a vaginal
delivery failed to progress. After measurement of the fetal head and a
trial of oxytocin, the patient underwent a cesarean section. What
condition should the coder suspect and query the physician about?
a. Twin pregnancy
b. Early delivery
c. Eclampsia
d. Cephalopelvic disproportion. Answer: d. Cephalopelvic
disproportion
◍ 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
coder 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.. Answer: c. Query the physician to
determine if there was a complication of surgery.
◍ If a patient's discharge summary does not contain a diagnosis that
is documented by the anesthesiologist in a preoperative evaluation
and that would impact MS-DRG assignment, the coder should:
a. Code only from the discharge diagnosis
b. Code the diagnosis reflected on the anesthesia preoperative
evaluation
c. Code the most severe symptom
d. Query the attending physician regarding the clinical significance of
that diagnosis. Answer: d. Query the attending physician regarding the
clinical significance of that diagnosis
◍ A patient has documentation of esophageal varices. What condition
may be related that may affect the coding?
a. Arthritis
b. Liver disease
c. Chronic obstructive pulmonary disease
d. Erythema. Answer: b. Liver disease
,◍ A patient admitted with acute abdominal pain, is fount to have
appendicitis, and has an appendectomy. The patient has a length of
stay for 2 days. What type of patient encounter is this?
a. Impatient
b. Outpatient
c. Long term care
d. Rehabilitation. Answer: a. Inpatient
◍ A patient was treated in the emergency department for a swollen
knee and an aspiration of the joint was performed. The patient was
then discharged home. It is important to make sure that which of the
following are documented and captured for billing purposes?
a. X-ray and other types of radiology examination
b. Procedures performed including the aspiration of the joint
c. Examination and management in the emergency department
d. All services provided including diagnostic and treatment
procedures, as well as physician services. Answer: d. All services
provided including diagnostic and treatment procedures, as well as
physician services.
◍ A patient has documentation on the discharge summary of
urosepsis. The coding staff queries the attending physician about the
condition and is provided further information that the patient has
septicemia. This is in alignment with the laboratory test and
medication given but the diagnosis of septicemia was not documented
by the physician. How should the physician be requested to document
the septicemia?
, a. A brand new history and physical should be dictated to replace the
one in the record.
b. An addendum to the chart should be written.
c. The new information should be squeezed in between lines within
the progress notes of the last day.
d. The query sheet will be sufficient to document this information..
Answer: b. An addendum to the chart should be written.
◍ The committee responsible for medical record completion reports
to which medical staff committee?
a. Chief executive officer of the facility
b. Medical Executive Committee
c. Discharge Planning Committee
d. Chief nursing officer. Answer: b. Medical Executive Committee
◍ Two areas of documentation in the medial record that are
significant areas of focus of accrediting agencies are:
a. Incident reports notion in the medical record and attorney's notes
b. Past medical reports and social worker notes
c. Timeliness and legibility of medical documents
d. Patient documentation and pastoral counseling. Answer: c.
Timeliness and legibility of medical documents
◍ In teaching facilities where electronic signatures are used for
residents and attending physicians:
a. Attending signature is all that is needed
