Certified Clinical Documentation Specialist
(CCDS) Exam With Questions And Answers
A. Bleeding gastric ulcer
A patient is admitted from the emergency department (ED) with a diagnosis of
weakness and anemia. After admission and further treatment with packed red blood
cells (PRBC), GI consult, and endoscopy, the physician includes the following diagnoses
in the discharge summary: anemia, suspected bleeding gastric ulcer, and GERD. What
would be the most appropriate principle diagnosis?
A. Bleeding gastric ulcer
B. Anemia
C. GERD
D. Weakness
B. Neoplasm of occipital region
A patient is admitted with new-onset seizures. Head CT reveals a mass in the occipital
region. The physician documents possible brain tumor, and the patient is transferred to
another hospital for further workup. What would be the most appropriate principal
diagnosis based upon this documentation?
A. Seizure
B. Neoplasm of occipital region
C. Head mass
D. Head tumor
,C. 1,2, and 3
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new technology
3. Adjusted based upon number of low-income patients cared for
A hospital's base rate or blended rate is:
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new technology
3. Adjusted based upon number of low-income patients cared for
4. Not adjusted based upon capital expenses
A. 1 and 2
B. 2 and 3
C. 1,2, and 3
D. 1,2,3, and 4
D. Reflect the severity of illness (SOI) and resource consumption of the patient's care
The final MS-DRG assigned to a patient's medical record should:
A. Reflect the amount of time the physician spent with the patient
,B. Depend upon the patient's length of stay
C. Be assigned by the physician
D. Reflect the severity of illness (SOI) and resource consumption of the patient's care
C. Poisoning
A patient is admitted from the emergency department with the diagnosis of acute
respiratory failure due to overdose of pain medication and an aspiration pneumonia.
What is the principal diagnosis?
A. Acute respiratory failure
B. Aspiration pneumonia
C. Poisoning
D. Adverse effect of medication
D. All of the conditions should be coded
A patient is admitted with pneumonia, stage 1 chronic renal failure, chronic anemia, and
COPD, While hospitalized the patient receives IV antibiotics, inhalers, oxygen, IV fluids at
50mL/hr, and iron tablets. Keeping the guidelines for coding of secondary diagnoses in
mind, which condition should be coded?
A. Pneumonia only
B. Pneumonia and COPD only
C. Pneumonia, COPD, and anemia
D. All of the conditions should be coded
, D. Fractured ulna
Which of the following is an example of a hospital-acquired condition?
A. Fat embolism
B. IV phlebitis
C. Pneumonia
D. Fractured ulna
C. A diagnosis that is listed as possible in the history and physical
Which of the following is an example of documentation that would meet the present on
admission criteria for coding?
A. A diagnosis that is indicated in the history and physical and ruled out in the discharge
summary
B. A diagnosis found in a previous medical record
C. A diagnosis that is listed as possible in the history and physical
D. An acute condition identified on the third day of admission
A. Colon cancer
A patient is admitted with abdominal pain and the history and physical indicated a
diagnosis of probable colon cancer. On day two, the physician documents acute renal
failure in the progress notes and the patient receives IV fluids. The discharge summary
(CCDS) Exam With Questions And Answers
A. Bleeding gastric ulcer
A patient is admitted from the emergency department (ED) with a diagnosis of
weakness and anemia. After admission and further treatment with packed red blood
cells (PRBC), GI consult, and endoscopy, the physician includes the following diagnoses
in the discharge summary: anemia, suspected bleeding gastric ulcer, and GERD. What
would be the most appropriate principle diagnosis?
A. Bleeding gastric ulcer
B. Anemia
C. GERD
D. Weakness
B. Neoplasm of occipital region
A patient is admitted with new-onset seizures. Head CT reveals a mass in the occipital
region. The physician documents possible brain tumor, and the patient is transferred to
another hospital for further workup. What would be the most appropriate principal
diagnosis based upon this documentation?
A. Seizure
B. Neoplasm of occipital region
C. Head mass
D. Head tumor
,C. 1,2, and 3
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new technology
3. Adjusted based upon number of low-income patients cared for
A hospital's base rate or blended rate is:
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new technology
3. Adjusted based upon number of low-income patients cared for
4. Not adjusted based upon capital expenses
A. 1 and 2
B. 2 and 3
C. 1,2, and 3
D. 1,2,3, and 4
D. Reflect the severity of illness (SOI) and resource consumption of the patient's care
The final MS-DRG assigned to a patient's medical record should:
A. Reflect the amount of time the physician spent with the patient
,B. Depend upon the patient's length of stay
C. Be assigned by the physician
D. Reflect the severity of illness (SOI) and resource consumption of the patient's care
C. Poisoning
A patient is admitted from the emergency department with the diagnosis of acute
respiratory failure due to overdose of pain medication and an aspiration pneumonia.
What is the principal diagnosis?
A. Acute respiratory failure
B. Aspiration pneumonia
C. Poisoning
D. Adverse effect of medication
D. All of the conditions should be coded
A patient is admitted with pneumonia, stage 1 chronic renal failure, chronic anemia, and
COPD, While hospitalized the patient receives IV antibiotics, inhalers, oxygen, IV fluids at
50mL/hr, and iron tablets. Keeping the guidelines for coding of secondary diagnoses in
mind, which condition should be coded?
A. Pneumonia only
B. Pneumonia and COPD only
C. Pneumonia, COPD, and anemia
D. All of the conditions should be coded
, D. Fractured ulna
Which of the following is an example of a hospital-acquired condition?
A. Fat embolism
B. IV phlebitis
C. Pneumonia
D. Fractured ulna
C. A diagnosis that is listed as possible in the history and physical
Which of the following is an example of documentation that would meet the present on
admission criteria for coding?
A. A diagnosis that is indicated in the history and physical and ruled out in the discharge
summary
B. A diagnosis found in a previous medical record
C. A diagnosis that is listed as possible in the history and physical
D. An acute condition identified on the third day of admission
A. Colon cancer
A patient is admitted with abdominal pain and the history and physical indicated a
diagnosis of probable colon cancer. On day two, the physician documents acute renal
failure in the progress notes and the patient receives IV fluids. The discharge summary
