CCS EXAM PREPARATION, DOMAIN 4 EXAM
QUESTIONS AND VERIFIED ANSWER; 100%
CORRECT; 2026- 2027 UPDATE
A coding professional is working from his work queue and gets
assigned the outpatient surgery record of the hospital
administrator. Is this an ethical issue? Why or why not?
A. Yes, only the coding supervisor should code the record of the
administrator
B. Yes, the coding professional should never work on a chart of
another hospital employee
C. No, the coding professional can code the record as normal
and look at previous encounters
D. No, the coding professional can assign codes for the
encounter without an ethical concern - correct answer-
D. No, the coding professional can assign codes for the
encounter without an ethical concern
As long as the coding professional performs his work as he
always does and only accesses the information necessary to
complete the chart, there is no ethical issue (AHIMA House of
Delegates 2016).
,A coding supervisor performs an internal audit on the coding
staff. The overall accuracy results are 85 percent and the
expectation is 95 percent. She decides to eliminate the worst
records from the audit in order to bolster the score which then
becomes 93 percent and will make her look better to her boss. Is
this ethically okay for her to do?
A. Yes, internal audit criteria are determined by the coding
supervisor and can be changed by her.
B. Yes, if her boss approves of the elimination of the records,
then it fine and there is no ethical issue.
C. No, only the HIM Director can make changes to the audit
including the number of records reviewed.
D. No, the audit criteria should not be altered to provide a better
score or improve the supervisor's status. - correct answer-
D. No, the audit criteria should not be altered to provide a better
score or improve the supervisor's status.
Once determined, audit criteria, including the number of charts
to be reviewed, should not be altered. This skews the scores and
will provide inaccurate information (AHIMA House of Delegates
2016).
,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?
A. Amendment
B. Addendum
C. Update
D. Revision - correct answer- A. Amendment
Once a document has been completed and signed, clarification
takes place through an amendment (Sayles 2020, 78).
A condition that is established after study to be chiefly
responsible for the admission is the:
A. Reason for visit
B. Principal procedure
C. A complication of outpatient care
D. Principal diagnosis - correct answer- D. Principal
diagnosis
The principal diagnosis is defined as the condition "established
after study to be chiefly responsible for occasioning the
admission of the patient to the hospital for care." Selecting the
, principal diagnosis depends on the circumstances of the
admission and why the patient was admitted (Schraffenberger
and Palkie 2022, 92; CMS 2021a, Section II, 101).
A contract coding professional works for a hospital and, in the
course of daily work, routinely accesses protected patient health
information. Under HIPAA, what should be in place to permit
access and protect patient privacy?
A. AHIMA credential
B. Business associate agreement
C. Vendor license
D. Patient authorization - correct answer- B. Business
associate agreement
A business associate agreement should be in place with vendors,
including contract coding professionals, to protect patient
privacy (Brodnik 2017, 346).
A diabetic patient was admitted for treatment of a pressure
ulcer. The patient also has a history of diabetic neuropathy and
retinopathy. The patient is blind and additional nursing care and
extended time with the patient was required. Which conditions
should be coded at discharge?
QUESTIONS AND VERIFIED ANSWER; 100%
CORRECT; 2026- 2027 UPDATE
A coding professional is working from his work queue and gets
assigned the outpatient surgery record of the hospital
administrator. Is this an ethical issue? Why or why not?
A. Yes, only the coding supervisor should code the record of the
administrator
B. Yes, the coding professional should never work on a chart of
another hospital employee
C. No, the coding professional can code the record as normal
and look at previous encounters
D. No, the coding professional can assign codes for the
encounter without an ethical concern - correct answer-
D. No, the coding professional can assign codes for the
encounter without an ethical concern
As long as the coding professional performs his work as he
always does and only accesses the information necessary to
complete the chart, there is no ethical issue (AHIMA House of
Delegates 2016).
,A coding supervisor performs an internal audit on the coding
staff. The overall accuracy results are 85 percent and the
expectation is 95 percent. She decides to eliminate the worst
records from the audit in order to bolster the score which then
becomes 93 percent and will make her look better to her boss. Is
this ethically okay for her to do?
A. Yes, internal audit criteria are determined by the coding
supervisor and can be changed by her.
B. Yes, if her boss approves of the elimination of the records,
then it fine and there is no ethical issue.
C. No, only the HIM Director can make changes to the audit
including the number of records reviewed.
D. No, the audit criteria should not be altered to provide a better
score or improve the supervisor's status. - correct answer-
D. No, the audit criteria should not be altered to provide a better
score or improve the supervisor's status.
Once determined, audit criteria, including the number of charts
to be reviewed, should not be altered. This skews the scores and
will provide inaccurate information (AHIMA House of Delegates
2016).
,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?
A. Amendment
B. Addendum
C. Update
D. Revision - correct answer- A. Amendment
Once a document has been completed and signed, clarification
takes place through an amendment (Sayles 2020, 78).
A condition that is established after study to be chiefly
responsible for the admission is the:
A. Reason for visit
B. Principal procedure
C. A complication of outpatient care
D. Principal diagnosis - correct answer- D. Principal
diagnosis
The principal diagnosis is defined as the condition "established
after study to be chiefly responsible for occasioning the
admission of the patient to the hospital for care." Selecting the
, principal diagnosis depends on the circumstances of the
admission and why the patient was admitted (Schraffenberger
and Palkie 2022, 92; CMS 2021a, Section II, 101).
A contract coding professional works for a hospital and, in the
course of daily work, routinely accesses protected patient health
information. Under HIPAA, what should be in place to permit
access and protect patient privacy?
A. AHIMA credential
B. Business associate agreement
C. Vendor license
D. Patient authorization - correct answer- B. Business
associate agreement
A business associate agreement should be in place with vendors,
including contract coding professionals, to protect patient
privacy (Brodnik 2017, 346).
A diabetic patient was admitted for treatment of a pressure
ulcer. The patient also has a history of diabetic neuropathy and
retinopathy. The patient is blind and additional nursing care and
extended time with the patient was required. Which conditions
should be coded at discharge?
