CCS EXAM QUESTIONS WITH ANSWERS 2025/2026
GRADED A+
Secondary Dx - All conditions that coexist at the time of admission, that develop
subsequently, or that affect the treatment received and/or length of stay.
Include comorbidities and complications
Comorbidity - Any condition that coexists during the relevant episode of car and
EFFECTS THE TREATMENT PROVIDED TO THE PATIENT
(what patient comes in the door with)
pre-exisiting condition that will affect treatment or increase the patients length of stay
Complication - Any condition that arises during the relevant episode of care and
EFFECTS THE TREATMENT PROVIDED TO THE PATIENT
Ex. post-op complications, injuries that arise during the stay
Arises AFTER the patient s admission to the hospital
Principle Procedure - A procedure that was performed for definitive treatment rather
than one performed for diagnostic or exploratory purposes, or was necessary to take
care of a complication.
If you have 2 procedures that appear to be principle then the one most related to the......
- principle diagnosis should be selected as the principle procedure
What 2 items are not a required data element of the UHDDS guidelines? - Admitting Dx
Patient Name
Admitting Dx - What the physician suspects is wrong with the patient
"tentative or provisional dx"
Juvenile Onset Diabetes - Type 1 Diabetes
Develops due to absence of insulin production (insulinopenia)
Not determined by age
Requires an injection of insulin to maintain normal glucose levels
Commonly Used Insulins - Humulin
Semi-Lente
Iletin
NPH Insulin
Novolog
Ultralente
Humalog
Novolin
Lenti
Lantus
, Adult On set Diabetes - Type 2 Diabetes
Formerly known as NIDDM (non insulin dependent diabetes mellitus)
Insulin Requiring Diabetes
Patient is not dependent on insulin to live
Prone to develop dehydration
Insulinopenia - abscence of insulin production
Impaired Glucose Tolerence - Dx given to people who have blood sugar levels higher
than normal but not enough to be given the dx of diabetes
Brittle Diabetic - Blood sugars quickly swing from high to low and from low to high
(unstable)
Extrinsic Asthma - patients with this type of asthma have a family hx of asthma
Review Of Systems - Physician asks patient a series of questions about how they feel.
Usually organized by body system
The physician does not touch the patient during ROS
Impression - Physicians opinion on what is wrong with the patient (admitting dx)
Timing of H&P - Must be documented within 24hrs of admission
Must be documented before surgery
Can be documented no more than 7 days prior to admission
If pt is readmitted within 30 days for the same condition the physician may use an
"interval note"
Standing Orders - Orders established by a physician that apply to a particular dx or
condition
Verbal Orders - Usually by telephone
According to Medicare Conditions Of Participation state verbal order should be
authenticated within 48 hrs
Discharge Orders - Written at time physician decides patient is ready to go home or be
transferred to another facility
Clinical Information - Medical Hx
Dx Theraputic Orders
Observations
Purpose of Uniform Healthcare Data Sets - Ensure data collection for every patient is
consistent
Enables comparison of health care data on a national level for analysis
GRADED A+
Secondary Dx - All conditions that coexist at the time of admission, that develop
subsequently, or that affect the treatment received and/or length of stay.
Include comorbidities and complications
Comorbidity - Any condition that coexists during the relevant episode of car and
EFFECTS THE TREATMENT PROVIDED TO THE PATIENT
(what patient comes in the door with)
pre-exisiting condition that will affect treatment or increase the patients length of stay
Complication - Any condition that arises during the relevant episode of care and
EFFECTS THE TREATMENT PROVIDED TO THE PATIENT
Ex. post-op complications, injuries that arise during the stay
Arises AFTER the patient s admission to the hospital
Principle Procedure - A procedure that was performed for definitive treatment rather
than one performed for diagnostic or exploratory purposes, or was necessary to take
care of a complication.
If you have 2 procedures that appear to be principle then the one most related to the......
- principle diagnosis should be selected as the principle procedure
What 2 items are not a required data element of the UHDDS guidelines? - Admitting Dx
Patient Name
Admitting Dx - What the physician suspects is wrong with the patient
"tentative or provisional dx"
Juvenile Onset Diabetes - Type 1 Diabetes
Develops due to absence of insulin production (insulinopenia)
Not determined by age
Requires an injection of insulin to maintain normal glucose levels
Commonly Used Insulins - Humulin
Semi-Lente
Iletin
NPH Insulin
Novolog
Ultralente
Humalog
Novolin
Lenti
Lantus
, Adult On set Diabetes - Type 2 Diabetes
Formerly known as NIDDM (non insulin dependent diabetes mellitus)
Insulin Requiring Diabetes
Patient is not dependent on insulin to live
Prone to develop dehydration
Insulinopenia - abscence of insulin production
Impaired Glucose Tolerence - Dx given to people who have blood sugar levels higher
than normal but not enough to be given the dx of diabetes
Brittle Diabetic - Blood sugars quickly swing from high to low and from low to high
(unstable)
Extrinsic Asthma - patients with this type of asthma have a family hx of asthma
Review Of Systems - Physician asks patient a series of questions about how they feel.
Usually organized by body system
The physician does not touch the patient during ROS
Impression - Physicians opinion on what is wrong with the patient (admitting dx)
Timing of H&P - Must be documented within 24hrs of admission
Must be documented before surgery
Can be documented no more than 7 days prior to admission
If pt is readmitted within 30 days for the same condition the physician may use an
"interval note"
Standing Orders - Orders established by a physician that apply to a particular dx or
condition
Verbal Orders - Usually by telephone
According to Medicare Conditions Of Participation state verbal order should be
authenticated within 48 hrs
Discharge Orders - Written at time physician decides patient is ready to go home or be
transferred to another facility
Clinical Information - Medical Hx
Dx Theraputic Orders
Observations
Purpose of Uniform Healthcare Data Sets - Ensure data collection for every patient is
consistent
Enables comparison of health care data on a national level for analysis
