CCS FINAL EXAM (2025 LATEST UPDATE) WITH 100%
VERIFIED CURRENTLY TESTING QUESTIONS ACCURATELY
SOLVED | GRADE A
45-year-old patient admitted with Insulin dependent diabetes. The type
of diabetes is not specified in the medical record. How should this be
coded?
a. E11.9, Z79.4
b. E11.8
c. E11.8, Z79.4
d. Z79.4, E11.8 - ANSWERS- a. E11.9, Z79.4
If the type of diabetes mellitus is not documented in the medical record the default is
E11.-, Type 2 diabetes mellitus. Code Z79.4, Long term (current) use of insulin,
should also be assigned for patients who take insulin (CMS 2018a, Section I.C.4.a.2,
34).
The patient is diagnosed with a recurrent thyroglossal duct cyst. The surgeon locates
the cyst using palpation, and an incision is created. The cyst is then excised. What is
the correct CPT code assignment for this service?
a. 60200
b. 60210
c. 60280
d. 60281 - ANSWERS- d. 60281
CPT code 60281 is accessed using index entry Cyst, thyroglossal duct, excision
resulting in code range 60280-60281. Code 60281 is correct for recurrent (AMA CPT
Professional Edition 2018, 385).
Most hospitals require a medical record is completed within:
a. 5 days
b. 10 days
c. 7 days
d. 30 days - ANSWERS- d. 30 days
,The Medicare Conditions of Participation and the Joint Commission require that the
medical record is completed no later than 30 days following discharge of the patient
(Brickner 2016, 84).
A patient is admitted with an acute inferior myocardial infarction and discharged
alive. Which condition would increase the MS-DRG weight?
a. Respiratory failure
b. Atrial fibrillation
c. Hypertension
d. History of myocardial infarction - ANSWERS- a. Respiratory failure
MS-DRG 280 (weight = 01.6577) for myocardial infarction with respiratory failure
would change the MS-DRG. MS-DRG 282 (weight = 00.75863) would be assigned
for myocardial infarction alone, with atrial fibrillation, with hypertension, and with
history of myocardial infarction (Medicare Grouper Version 35).
According to CPT, an endoscopy that is undertaken to the level of the midtransverse
colon would be coded as a:
a. Proctosigmoidoscopy
b. Sigmoidoscopy
c. Colonoscopy
d. Proctoscopy - ANSWERS- c. Colonoscopy
A colonoscopy is an examination of the entire colon, from the rectum to the cecum
that may include the terminal ileum. In general, a colonoscopy examines the colon to
a level of 60 cm or higher (Smith 2018, 135-136).
According to the UHDDS, in order to assign a code for another diagnosis,
documentation must be present that:
a. The condition is recorded in the patient record by a dietary clerk
b. The condition is present in the admission department data
c. The condition was clinically evaluated or therapeutically treated, extended the
length of hospital stay, or increased nursing care or monitoring
,d. The condition is considered to be essential by the family - ANSWERS- c. The
condition was clinically evaluated or therapeutically treated, extended the length of
hospital stay, or increased nursing care or monitoring
For reporting purposes the definition for other diagnoses is interpreted as additional
conditions that affect patient care in terms of requiring: clinical evaluation; or
therapeutic treatment; or diagnostic procedures; or extended length of hospital stay;
or increased nursing care or monitoring (CMS 2018a, Section III, 105-106).
To correct an entry in the medical record, the provider should:
a. Draw a single line through the error, add a note explaining the error, initial and
date, add the correct information in chronological order
b. Draw a double line through the error, initial and date, add the reason for the
correction
c. Draw a single line through the error, and add the correct information in
chronological order
d. Draw several lines through the error, obliterate the documentation as much as
possible, initial and date, add the correct information in chronological order -
ANSWERS- a. Draw a single line through the error, add a note explaining the error,
initial and date, add the correct information in chronological order
If an error is corrected, the healthcare provider who made the error should draw a
single line through the error, add a note explaining the error, initial and date it, and
add the correct information in chronological order (Sayles 2016, 65). Further,
AHIMA principles for health record documentation specify the prior statement as the
proper method for correcting an error in the paper-based records in order to
maintain a legally sound record. This process is based on the ASTM and HL7
standards for error correction (AHIMA e-HIM Work Group on Maintaining the Legal
EHR, 2005).
A patient was admitted to the emergency department with chest pain and was
diagnosed with aborted myocardial infarction with acute myocardial ischemia. There
was no prior cardiac surgery. The cardiac enzymes were normal. The appropriate
coding of the diagnosis for this case is:
a. I21.3, ST elevation (STEMI) myocardial infarction of unspecified site
b. I25.10, Atherosclerotic heart disease of native coronary artery without angina
pectoris
, c. I24.8, Other forms of acute ischemic heart disease
d. I24.0, Acute coronary thrombosis not resulting in myocardial infarction -
ANSWERS- d. I24.0, Acute coronary thrombosis not resulting in myocardial
infarction
Acute ischemic heart disease or acute myocardial ischemia in a patient does not
always indicate an infarction. It is often possible to prevent infarction by means of
surgery or the use of thrombolytic agents if the patient is treated promptly. Using the
main term, ischemia, then the subterms of myocardium and acute, the alphabetic
index reflects that I24.0 is the correct code for an acute myocardial ischemia without
myocardial infarction (Leon-Chisen 2018, 391).
After a patient is discharged from the hospital, the medical record must be reviewed
for:
a. Inclusion of all incident reports
b. Certain basic reports (for example, history and physical, discharge summary, etc.)
c. Voided prescription pads
d. Personal case notes from all mental health providers - ANSWERS- b.
Certain basic reports (for example, history and physical, discharge summary,
etc.)
In order to determine if a medical record is complete, it must be reviewed for certain
basic reports including the presence of a history and physical, signed progress notes,
and a discharge summary if applicable (Reynolds and Sharp 2016, 123-125). The
incident report should never be filed in the medical record (Carter and Palmer 2016,
522); voided prescription pads are not used during a patient hospitalization;
personal case notes from mental health providers are kept separate from the official
record. While there are a number of documents required for the hospital medical
record to be complete, the ones described in option b present the best answer
(Rinehart-Thompson 2017c, 189)
A 70-year-old patient was admitted with pneumonia. The history and physical
documented that the patient has a history of diabetes, hypertension, and migraine
headache about 10 years ago without recurrence. The patient was administered IV
antibiotics, metformin, and Altace during the hospitalization. Which conditions
would be reported at the time of discharge?
a. Pneumonia, diabetes, hypertension, and migraine headaches
b. Pneumonia, diabetes, hypertension, and history of migraine headaches
VERIFIED CURRENTLY TESTING QUESTIONS ACCURATELY
SOLVED | GRADE A
45-year-old patient admitted with Insulin dependent diabetes. The type
of diabetes is not specified in the medical record. How should this be
coded?
a. E11.9, Z79.4
b. E11.8
c. E11.8, Z79.4
d. Z79.4, E11.8 - ANSWERS- a. E11.9, Z79.4
If the type of diabetes mellitus is not documented in the medical record the default is
E11.-, Type 2 diabetes mellitus. Code Z79.4, Long term (current) use of insulin,
should also be assigned for patients who take insulin (CMS 2018a, Section I.C.4.a.2,
34).
The patient is diagnosed with a recurrent thyroglossal duct cyst. The surgeon locates
the cyst using palpation, and an incision is created. The cyst is then excised. What is
the correct CPT code assignment for this service?
a. 60200
b. 60210
c. 60280
d. 60281 - ANSWERS- d. 60281
CPT code 60281 is accessed using index entry Cyst, thyroglossal duct, excision
resulting in code range 60280-60281. Code 60281 is correct for recurrent (AMA CPT
Professional Edition 2018, 385).
Most hospitals require a medical record is completed within:
a. 5 days
b. 10 days
c. 7 days
d. 30 days - ANSWERS- d. 30 days
,The Medicare Conditions of Participation and the Joint Commission require that the
medical record is completed no later than 30 days following discharge of the patient
(Brickner 2016, 84).
A patient is admitted with an acute inferior myocardial infarction and discharged
alive. Which condition would increase the MS-DRG weight?
a. Respiratory failure
b. Atrial fibrillation
c. Hypertension
d. History of myocardial infarction - ANSWERS- a. Respiratory failure
MS-DRG 280 (weight = 01.6577) for myocardial infarction with respiratory failure
would change the MS-DRG. MS-DRG 282 (weight = 00.75863) would be assigned
for myocardial infarction alone, with atrial fibrillation, with hypertension, and with
history of myocardial infarction (Medicare Grouper Version 35).
According to CPT, an endoscopy that is undertaken to the level of the midtransverse
colon would be coded as a:
a. Proctosigmoidoscopy
b. Sigmoidoscopy
c. Colonoscopy
d. Proctoscopy - ANSWERS- c. Colonoscopy
A colonoscopy is an examination of the entire colon, from the rectum to the cecum
that may include the terminal ileum. In general, a colonoscopy examines the colon to
a level of 60 cm or higher (Smith 2018, 135-136).
According to the UHDDS, in order to assign a code for another diagnosis,
documentation must be present that:
a. The condition is recorded in the patient record by a dietary clerk
b. The condition is present in the admission department data
c. The condition was clinically evaluated or therapeutically treated, extended the
length of hospital stay, or increased nursing care or monitoring
,d. The condition is considered to be essential by the family - ANSWERS- c. The
condition was clinically evaluated or therapeutically treated, extended the length of
hospital stay, or increased nursing care or monitoring
For reporting purposes the definition for other diagnoses is interpreted as additional
conditions that affect patient care in terms of requiring: clinical evaluation; or
therapeutic treatment; or diagnostic procedures; or extended length of hospital stay;
or increased nursing care or monitoring (CMS 2018a, Section III, 105-106).
To correct an entry in the medical record, the provider should:
a. Draw a single line through the error, add a note explaining the error, initial and
date, add the correct information in chronological order
b. Draw a double line through the error, initial and date, add the reason for the
correction
c. Draw a single line through the error, and add the correct information in
chronological order
d. Draw several lines through the error, obliterate the documentation as much as
possible, initial and date, add the correct information in chronological order -
ANSWERS- a. Draw a single line through the error, add a note explaining the error,
initial and date, add the correct information in chronological order
If an error is corrected, the healthcare provider who made the error should draw a
single line through the error, add a note explaining the error, initial and date it, and
add the correct information in chronological order (Sayles 2016, 65). Further,
AHIMA principles for health record documentation specify the prior statement as the
proper method for correcting an error in the paper-based records in order to
maintain a legally sound record. This process is based on the ASTM and HL7
standards for error correction (AHIMA e-HIM Work Group on Maintaining the Legal
EHR, 2005).
A patient was admitted to the emergency department with chest pain and was
diagnosed with aborted myocardial infarction with acute myocardial ischemia. There
was no prior cardiac surgery. The cardiac enzymes were normal. The appropriate
coding of the diagnosis for this case is:
a. I21.3, ST elevation (STEMI) myocardial infarction of unspecified site
b. I25.10, Atherosclerotic heart disease of native coronary artery without angina
pectoris
, c. I24.8, Other forms of acute ischemic heart disease
d. I24.0, Acute coronary thrombosis not resulting in myocardial infarction -
ANSWERS- d. I24.0, Acute coronary thrombosis not resulting in myocardial
infarction
Acute ischemic heart disease or acute myocardial ischemia in a patient does not
always indicate an infarction. It is often possible to prevent infarction by means of
surgery or the use of thrombolytic agents if the patient is treated promptly. Using the
main term, ischemia, then the subterms of myocardium and acute, the alphabetic
index reflects that I24.0 is the correct code for an acute myocardial ischemia without
myocardial infarction (Leon-Chisen 2018, 391).
After a patient is discharged from the hospital, the medical record must be reviewed
for:
a. Inclusion of all incident reports
b. Certain basic reports (for example, history and physical, discharge summary, etc.)
c. Voided prescription pads
d. Personal case notes from all mental health providers - ANSWERS- b.
Certain basic reports (for example, history and physical, discharge summary,
etc.)
In order to determine if a medical record is complete, it must be reviewed for certain
basic reports including the presence of a history and physical, signed progress notes,
and a discharge summary if applicable (Reynolds and Sharp 2016, 123-125). The
incident report should never be filed in the medical record (Carter and Palmer 2016,
522); voided prescription pads are not used during a patient hospitalization;
personal case notes from mental health providers are kept separate from the official
record. While there are a number of documents required for the hospital medical
record to be complete, the ones described in option b present the best answer
(Rinehart-Thompson 2017c, 189)
A 70-year-old patient was admitted with pneumonia. The history and physical
documented that the patient has a history of diabetes, hypertension, and migraine
headache about 10 years ago without recurrence. The patient was administered IV
antibiotics, metformin, and Altace during the hospitalization. Which conditions
would be reported at the time of discharge?
a. Pneumonia, diabetes, hypertension, and migraine headaches
b. Pneumonia, diabetes, hypertension, and history of migraine headaches
