AHIMA CCS ACTUAL TEST QUESTIONS AND
ANSWERS SURE A+
✔✔A 23-year-old female is admitted for shock following treatment of a miscarriage. The
pathology report from the previous admission reveals that the patient had no decidua or
products of conception in the tissue removed. This encounter would be coded as:
a. O03.81, Spontaneous abortion complicated by shock
b. O08.9, Complication following abortion and ectopic and molar pregnancies
c. R57.9, Shock NOS
d. T81.10XA, Postoperative shock - ✔✔b. O08.9, Complication following abortion and
ectopic and molar pregnancies
✔✔The committee responsible for medical record completion reports to which medical
staff committee?
a. Compliance Committee
b. Medical Executive Committee
c. Discharge Planning Committee
d. Nursing Executive Committee - ✔✔b. Medical Executive Committee
✔✔A patient undergoes a colposcopy with endometrial biopsy. Which of the following is
correct?
a. The colposcopy and endometrial biopsy are represented by a combination code.
b. Two codes would be used with modifier -59 appended.
c. Two codes would be used in accordance with CPT code instructions.
d. Only one code is used and it does not state that it includes endometrial biopsy
specifically. - ✔✔c. Two codes would be used in accordance with CPT code
instructions.
✔✔When a Medicare patient receives an injection of IM penicillin G benzathine,
100,000 units only, what is the appropriate code assignment?
,96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug);
subcutaneous or intramuscular
96374 Therapeutic, prophylactic or diagnostic injection (specify substance or drug);
intravenous push, single or initial substance/drug
J0558 Injection, penicillin G benzathine, and penicillin G procaine 100,000 unitsJ0561
Injection, penicillin G benzathine, 100,000 units
a. 96372
b. J0558
c. 96374
d. 96372, J0561 - ✔✔d. 96372, J0561
✔✔If a patient has an excision of a malignant lesion of the skin, the CPT code is
determined by the body area from which the excision occurs and the:
a. Length of the lesion as described in the pathology report
b. Dimension of the specimen submitted as described in the pathology report
c. Width times the length of the lesion as described in the operative report
d. Diameter of the lesion as well as the margins excised as described in the operative
report - ✔✔d. Diameter of the lesion as well as the margins excised as described in the
operative report
✔✔The use of the outpatient code editor (OCE) is designed to:
a. Correct documentation of home health visits
b. Facilitate reporting of adverse drug events
c. Reduce the use of computer assisted coding
d. Identify incomplete or incorrect claims - ✔✔d. Identify incomplete or incorrect claims
✔✔A patient is admitted with a high temperature, lethargy, hypotension, tachycardia,
oliguria, and elevated WBC. The patient also has more than 100,000 organisms of
Escherichia coli per cc of urine. The attending physician documents "urosepsis." What
is the next step for the coder?
a. Code sepsis as the principal with a secondary diagnosis of urinary tract infection due
to E. coli.
b. Code urinary tract infection with sepsis as a secondary diagnosis.
c. Query the physician to determine if the patient is being treated for sepsis, highlighting
the clinical signs and symptoms.
d. Ask the physician whether the patient had septic shock so that this may be used as
the principal diagnosis. - ✔✔c. Query the physician to determine if the patient is being
treated for sepsis, highlighting the clinical signs and symptoms.
,✔✔A patient is admitted because of congestive heart failure (CHF). During the
treatment of the CHF, the patient was also found to have elevated liver function tests.
The physician worked up the elevated liver function tests but was not able to determine
a diagnosis. The following diagnoses should be assigned:
a. Congestive heart failure with liver disease
b. Abnormal liver function tests
c. Congestive heart failure and abnormal liver function tests
d. Congestive heart failure - ✔✔c. Congestive heart failure and abnormal liver function
tests
✔✔The use of standard protocols to enable different computer systems to communicate
is referred to as:
a. Digital assistance
b. A data set
c. Interoperability
d. Pay for communication - ✔✔c. Interoperability
✔✔Data accuracy is also referred to as:
a. Consistency
b. Comprehensiveness
c. Timeliness
d. Validity - ✔✔d. Validity
✔✔A routine computer back-up procedure is an example of a security program that
ensures data loss does not occur. This type of control is:
a. Computer
b. Validity
c. Responsive
d. Preventive - ✔✔d. Preventive
✔✔A bronchoscopy with biopsy of the left bronchus was completed and revealed
adenocarcinoma. What, if any, modifier should be added to the procedure codes?
a. −50, Bilateral procedure
b. −51, Multiple procedures
c. −LT, Left side
d. No modifiers should be reported. - ✔✔d. No modifiers should be reported.
✔✔Based on the AHIMA Code of Ethics, which of the following is not considered an
ethical activity?
, a. Coding audits
b. Using medical records for educational purposes within the department
c. Reviewing the history and physical of a coworker when not part of work assignment
d. Completion of code assignment - ✔✔c. Reviewing the history and physical of a
coworker when not part of work assignment
✔✔A 59-year-old female patient presents with acquired hallux valgus. Hallux valgus
repair is performed with resection of the joint with implant in the first left toe proximal
phalanx. What codes would be assigned?
a. M20.12, 28291-LT
b. M20.22, 28291-TA
c. M20.31, 28291-TA
d. M20.12, 28291-TA - ✔✔d. M20.12, 28291-TA
✔✔According to the UHDDS, the definition of a secondary diagnosis is a condition that:
a. Is recorded in the patient record
b. Receives evaluation and is documented by the physician
c. Receives clinical evaluation, therapeutic treatment, further evaluation, extends the
length of stay, increases nursing monitoring and care
d. Is considered to be essential by the physicians involved and is reflected in the record
- ✔✔c. Receives clinical evaluation, therapeutic treatment, further evaluation, extends
the length of stay, increases nursing monitoring and care
✔✔A facility located near a national park has a significant number of snake bites, and
patients receive treatment with antivenom in urgent-care settings. Sometimes a patient
is admitted to the hospital after several days. Can the urgent-care setting provide the
hospital with a list of names of patients treated with snake antivenom?
a. Only the names of patients who are admitted to the hospital can be requested if the
physician needs it for continuity of care, but an entire list of patients cannot be provided.
b. A list of names could be provided.
c. No information can be obtained under any circumstances.
d. A list of patients may be available after consultation with the national park ranger. -
✔✔a. Only the names of patients who are admitted to the hospital can be requested if
the physician needs it for continuity of care, but an entire list of patients cannot be
provided.
✔✔An 84-year-old woman was admitted and discharged with hemiplegia and aphasia.
A CT scan of the brain was performed that revealed an acute cerebral infarction and a
possible small brain mass. After further testing, the patient was discharged with a final
diagnosis of acute cerebral infarction. The condition(s) that should be coded are:
a. Acute cerebral infarction
ANSWERS SURE A+
✔✔A 23-year-old female is admitted for shock following treatment of a miscarriage. The
pathology report from the previous admission reveals that the patient had no decidua or
products of conception in the tissue removed. This encounter would be coded as:
a. O03.81, Spontaneous abortion complicated by shock
b. O08.9, Complication following abortion and ectopic and molar pregnancies
c. R57.9, Shock NOS
d. T81.10XA, Postoperative shock - ✔✔b. O08.9, Complication following abortion and
ectopic and molar pregnancies
✔✔The committee responsible for medical record completion reports to which medical
staff committee?
a. Compliance Committee
b. Medical Executive Committee
c. Discharge Planning Committee
d. Nursing Executive Committee - ✔✔b. Medical Executive Committee
✔✔A patient undergoes a colposcopy with endometrial biopsy. Which of the following is
correct?
a. The colposcopy and endometrial biopsy are represented by a combination code.
b. Two codes would be used with modifier -59 appended.
c. Two codes would be used in accordance with CPT code instructions.
d. Only one code is used and it does not state that it includes endometrial biopsy
specifically. - ✔✔c. Two codes would be used in accordance with CPT code
instructions.
✔✔When a Medicare patient receives an injection of IM penicillin G benzathine,
100,000 units only, what is the appropriate code assignment?
,96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug);
subcutaneous or intramuscular
96374 Therapeutic, prophylactic or diagnostic injection (specify substance or drug);
intravenous push, single or initial substance/drug
J0558 Injection, penicillin G benzathine, and penicillin G procaine 100,000 unitsJ0561
Injection, penicillin G benzathine, 100,000 units
a. 96372
b. J0558
c. 96374
d. 96372, J0561 - ✔✔d. 96372, J0561
✔✔If a patient has an excision of a malignant lesion of the skin, the CPT code is
determined by the body area from which the excision occurs and the:
a. Length of the lesion as described in the pathology report
b. Dimension of the specimen submitted as described in the pathology report
c. Width times the length of the lesion as described in the operative report
d. Diameter of the lesion as well as the margins excised as described in the operative
report - ✔✔d. Diameter of the lesion as well as the margins excised as described in the
operative report
✔✔The use of the outpatient code editor (OCE) is designed to:
a. Correct documentation of home health visits
b. Facilitate reporting of adverse drug events
c. Reduce the use of computer assisted coding
d. Identify incomplete or incorrect claims - ✔✔d. Identify incomplete or incorrect claims
✔✔A patient is admitted with a high temperature, lethargy, hypotension, tachycardia,
oliguria, and elevated WBC. The patient also has more than 100,000 organisms of
Escherichia coli per cc of urine. The attending physician documents "urosepsis." What
is the next step for the coder?
a. Code sepsis as the principal with a secondary diagnosis of urinary tract infection due
to E. coli.
b. Code urinary tract infection with sepsis as a secondary diagnosis.
c. Query the physician to determine if the patient is being treated for sepsis, highlighting
the clinical signs and symptoms.
d. Ask the physician whether the patient had septic shock so that this may be used as
the principal diagnosis. - ✔✔c. Query the physician to determine if the patient is being
treated for sepsis, highlighting the clinical signs and symptoms.
,✔✔A patient is admitted because of congestive heart failure (CHF). During the
treatment of the CHF, the patient was also found to have elevated liver function tests.
The physician worked up the elevated liver function tests but was not able to determine
a diagnosis. The following diagnoses should be assigned:
a. Congestive heart failure with liver disease
b. Abnormal liver function tests
c. Congestive heart failure and abnormal liver function tests
d. Congestive heart failure - ✔✔c. Congestive heart failure and abnormal liver function
tests
✔✔The use of standard protocols to enable different computer systems to communicate
is referred to as:
a. Digital assistance
b. A data set
c. Interoperability
d. Pay for communication - ✔✔c. Interoperability
✔✔Data accuracy is also referred to as:
a. Consistency
b. Comprehensiveness
c. Timeliness
d. Validity - ✔✔d. Validity
✔✔A routine computer back-up procedure is an example of a security program that
ensures data loss does not occur. This type of control is:
a. Computer
b. Validity
c. Responsive
d. Preventive - ✔✔d. Preventive
✔✔A bronchoscopy with biopsy of the left bronchus was completed and revealed
adenocarcinoma. What, if any, modifier should be added to the procedure codes?
a. −50, Bilateral procedure
b. −51, Multiple procedures
c. −LT, Left side
d. No modifiers should be reported. - ✔✔d. No modifiers should be reported.
✔✔Based on the AHIMA Code of Ethics, which of the following is not considered an
ethical activity?
, a. Coding audits
b. Using medical records for educational purposes within the department
c. Reviewing the history and physical of a coworker when not part of work assignment
d. Completion of code assignment - ✔✔c. Reviewing the history and physical of a
coworker when not part of work assignment
✔✔A 59-year-old female patient presents with acquired hallux valgus. Hallux valgus
repair is performed with resection of the joint with implant in the first left toe proximal
phalanx. What codes would be assigned?
a. M20.12, 28291-LT
b. M20.22, 28291-TA
c. M20.31, 28291-TA
d. M20.12, 28291-TA - ✔✔d. M20.12, 28291-TA
✔✔According to the UHDDS, the definition of a secondary diagnosis is a condition that:
a. Is recorded in the patient record
b. Receives evaluation and is documented by the physician
c. Receives clinical evaluation, therapeutic treatment, further evaluation, extends the
length of stay, increases nursing monitoring and care
d. Is considered to be essential by the physicians involved and is reflected in the record
- ✔✔c. Receives clinical evaluation, therapeutic treatment, further evaluation, extends
the length of stay, increases nursing monitoring and care
✔✔A facility located near a national park has a significant number of snake bites, and
patients receive treatment with antivenom in urgent-care settings. Sometimes a patient
is admitted to the hospital after several days. Can the urgent-care setting provide the
hospital with a list of names of patients treated with snake antivenom?
a. Only the names of patients who are admitted to the hospital can be requested if the
physician needs it for continuity of care, but an entire list of patients cannot be provided.
b. A list of names could be provided.
c. No information can be obtained under any circumstances.
d. A list of patients may be available after consultation with the national park ranger. -
✔✔a. Only the names of patients who are admitted to the hospital can be requested if
the physician needs it for continuity of care, but an entire list of patients cannot be
provided.
✔✔An 84-year-old woman was admitted and discharged with hemiplegia and aphasia.
A CT scan of the brain was performed that revealed an acute cerebral infarction and a
possible small brain mass. After further testing, the patient was discharged with a final
diagnosis of acute cerebral infarction. The condition(s) that should be coded are:
a. Acute cerebral infarction
