CCS ACTUAL TEST PAPER EXAM 2025/2026 QUESTIONS
WITH SOLUTIONS GRADED A+
✔✔23 yo female admitted for shock following tx of miscarriage and path report from
prev admit reveals pt had no decidua or POC in tissue removed. Encounter would be
coded as: - ✔✔O08.9 = complication following abortion and ectopic and molar
pregnancies since miscarriage was dealt with in a prior episode of care
✔✔Most hospitals require a medical record is completed within: - ✔✔30 days due to
Medicare CofP and TJC
✔✔To correct an entry in the MR, the provider should: - ✔✔Draw single line through the
error, add a note explaining the error, initial, date, and add correct info in chronological
order
✔✔After pt is discharged from hospital, the MR must be reviewed for: - ✔✔Certain basic
reports such as history and physical, discharge summary, etc.
✔✔Pt is discharged with diagnosis of acute pulmonary edema due to CHF so what
cn(s) should be coded? - ✔✔CHF
✔✔Pt is admitted for chest pain, was stabilized and discharged. In subsequent adm, pt
was admitted an outpt for left heart catheterization, coronary arteriography using 2
catheters, left ventricular angiography, and found to have arteriosclerotic heart disease.
Pt has no hx of cardiac surgery. What is the proper sequencing of ICD-10-CM and CPT
codes for outpt catheterization? - ✔✔I25.10 (Atherosclerotic heart disease of native
coronary artery without angina pectoris)
93458 (Catheter placement in coronary artery(s) for coronary angiography, incl
intraprocedural injection(s) for coronary angiography, imaging supervision and
interpretation with left heart catheterization including intraprocedural injection(s) for left
ventriculography, when performed
✔✔65yo pt adm w/pain and loosening of left total hip prosthesis along with the
loosening of the acetabular component which has become painful. Pt ad for open
removal/replacement of acetabular component of left hip prosthesis, so what is the
correct coding for admission? - ✔✔T84.031A (mechanical loosening of int lt hip prosth
jt, initial enc
0SPB0JZ (removal synthetic sub fro lt hip jt, open approach
0SRE0JZ (replacement lt hip jt, acetabular surface w/synthetic sub, open approach)
✔✔Maternity pt adm in labor at 43 wks and has normal delivery with vacuum extraction
to facilitate baby's delivery. What is the PD? - ✔✔O48.1 (prolonged pg)
,✔✔With regard to implementation of ICD-10-CM, all of these are correct: - ✔✔ICD-10-
CM was developed by NCHS; it was implemented on 10/1/15; was already being used
by death certificate coding in US; the process of adopting ICD-10-CM is specified in
HIPAA
✔✔What does NCHS stand for? - ✔✔National Center for Health Statistics
✔✔75yo female was adm for AMI and underwent a diagnostic cardiac cath. Following
the cath, pt dev a thrombophlebitis documented as due to the catheter in the common
femoral artery. The thrombophlebitis would be coded as: - ✔✔T81.718A, complication
of other artery following a procedure, NEC, initial enc
✔✔Pt adm to ED w/chest pain, and dx w/abort MI w/acute myocardial ischemia with no
prior cardiac surgery, and normal cardiac enzymes. What is coding for this case? -
✔✔I24.0 (acute coronary thrombosis not resulting in MI) Pts w/acute ischemic heart
disease or acute myocardial ischemia do not always indicate an infarction and it is often
possible to prevent infarction by means of surgery or use of thrombolytic agents if tx
promptly
✔✔Pt has nausea, vomiting, abdominal pain due to acute cholecystitis. Phys doc the
following on DS: Acute cholecystitis, nausea, vomiting, and abdominal pain. What is
correct coding? - ✔✔Acute cholecystitis
✔✔Pt adm bc of CHF, and also found to have elevated liver function tests. Phys worked
up ELF test but able to determine dx, so the following dx is assigned: - ✔✔CHF and
abnormal liver function tests
✔✔Pt adm with hypotension due to dobutamine taken and prescribed correctly. How is
this coded? - ✔✔I95.2, Hypotension due to drugs
T44.5X5A, adverse effects of dobutamine
✔✔Pt adm 2 wks after laminectomy for spinal stenosis w/headache (headache due to
tear in dura accidentally occurred during prior laminectomy surgery). Pt taken to OR for
repair of dura. How is this case coded? - ✔✔G97.41, Accidental puncture or laceration
of dura during procedure
✔✔Pt adm w/SOB, CHF, and subsequently dev resp fail. Pt undergoes intubation
w/ventilator mgmt. Correct seq of dx would be: - ✔✔CHF and resp failure
✔✔Pt adm w/pneumococcal pneumonia and pneumococcal sepsis, so the coder
should: - ✔✔Assign code for sepsis, pneumonia, and severe sepsis. Pt
w/pneumococcal sepsis and pneumococcal pneumonia also has severe sepsis and
,Guidelines provide info related to coding, seq of sepsis, severe sepsis, and localized
infection, such as pneumonia
✔✔Pt adm w/ESRD following kidney transplant, who also had angina and COPD, so dx
would be seq as: - ✔✔ESRD; status post kidney transplant; COPD; angina
✔✔Pt adm to hosp due to fracture of rt hip and scheduled for open reduction with int fix,
but pt dev cardiac arrhythmia which results in an inability to do planned surgery. Assign
code for PD: - ✔✔Rt hip fracture (cond after study that occasioned adm should be seq
first even if the plan of tx was not carried out due to unforeseen circumstances)
✔✔What is not part of a facility coding compliance plan? - ✔✔Coding audits performed
by payers (while this has value, payers are considered external reviewing)
✔✔What are various parts of a facility coding compliance plan? - ✔✔Regular internal
audits, audits performed by objective external reviewers, sharing/discussing results with
coding staff
✔✔In CPT, unlisted codes are reported only if: - ✔✔There is a not a HCPCS level II or a
current CPT level III code available
✔✔A virtual screening colonoscopy would be coded as: - ✔✔74263: Computed
tomographic (CT) colonography, screening including image postprocessing
✔✔Pt underwent excision of malignant lesion of chest measuring 1.0cm with 0.2cm
margin, and based on 2015 CPT codes, which code is used for this procedure? -
✔✔11602, Excision malignant lesion of trunk; excised diameter 1.1-2.0cm
✔✔Pt dx w/L4-5 lumbar neuropathy and discogenic pain. Pt underwent percutaneous
intradiscal electrothermal annuloplasty (IDET) in radiology suite. What ICD-10-PCS
code should be used? - ✔✔0S523ZZ, Destruction, lumbar vertebral disc, percutaneous
(IDET is done w/thermal energy, or heat, directed into the outer disc wall, or annulus,
and inner disc contents, or nucleus, via a heating coil, decreasing pressure inside the
disc
✔✔Laparoscopic tubal ligation with Falope ring is completed, so what is correct CPT
code assignment? - ✔✔58671, Laparoscopy, surgical; with occlusion of oviducts by
device (band, clip, or Falope ring)
✔✔Carcinoma of multiple overlapping sites of the bladder, so dx cystoscopy and
transurethral fulguration of bladder lesions (1.9cm, 6.0 cm) are undertaken. The
appropriate CPT code(s) would be: - ✔✔52240, Cystourethroscopy, with fulguration
(including cryosurgery or laser surgery) and/or resection of lg bladder tumor(s)
, ✔✔Pt presents to facility for upper endoscopy implant of material into muscle of lower
esophageal sphincter, so what is correct coding, seq of pt's record? - ✔✔43236, Upper
gastrointestinal endoscopy including esophagus, stomach, and either the duodenum
and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by
brushing or washing (separate procedure) with directed submucosal injection(s), any
substance
✔✔Pt undergoes colposcopy with endometrial biopsy, so how many codes does is this
case req? - ✔✔Two codes would be used in accordance with 2015 CPT code revisions
✔✔Pt present to outpt surgical area for cystoscopy with mult biopsies of the bladder,
and pt's presenting symptom is hematuria, so what is the correct code assignment this
procedure? - ✔✔52204, Cystourethroscopy with biopsy(s)
✔✔If pt has excision of malignant lesion of the skin, the CPT code is determined by the
body area from which the excision occurs and the: - ✔✔Diameter of lesion as well as
margins excised as described in Op Report
✔✔When coding arthrocentesis, the code assignment is determined by: - ✔✔Size of the
jt since arthrocentesis codes are based on whether jt is small, intermediate, or major
✔✔Assign correct code for open total cholecystectomy with exploration of common bile
duct and removal of common bile duct stone: - ✔✔0FT40ZZ, resection gallbladder,
open approach
0FC90ZZ, removal, common bile duct stone, open
✔✔Assign correct code for total laparoscopic cholecystectomy with percutaneous
removal of common bile duct stone: - ✔✔0FT44ZZ, Resection, gallbladder, Resection of
gallbladder, percutaneous endoscopic approach
0FC94ZZ, Removal, common bile duct stones, laparoscopic
✔✔Assign correct code for total open cholecystectomy with intraoperative
cholangiogram (done w/plain radiography with low osmolar contrast): - ✔✔0FC94ZZ,
Removal, common bile duct stones, laparoscopic
0FT40ZZ, Resection, gallbladder, open approach
✔✔Removal of the entire body part and removal of an entire lobe of the liver is what
root operation? - ✔✔Resection
✔✔Inpt procedures are code with: - ✔✔ICD-10-CM
WITH SOLUTIONS GRADED A+
✔✔23 yo female admitted for shock following tx of miscarriage and path report from
prev admit reveals pt had no decidua or POC in tissue removed. Encounter would be
coded as: - ✔✔O08.9 = complication following abortion and ectopic and molar
pregnancies since miscarriage was dealt with in a prior episode of care
✔✔Most hospitals require a medical record is completed within: - ✔✔30 days due to
Medicare CofP and TJC
✔✔To correct an entry in the MR, the provider should: - ✔✔Draw single line through the
error, add a note explaining the error, initial, date, and add correct info in chronological
order
✔✔After pt is discharged from hospital, the MR must be reviewed for: - ✔✔Certain basic
reports such as history and physical, discharge summary, etc.
✔✔Pt is discharged with diagnosis of acute pulmonary edema due to CHF so what
cn(s) should be coded? - ✔✔CHF
✔✔Pt is admitted for chest pain, was stabilized and discharged. In subsequent adm, pt
was admitted an outpt for left heart catheterization, coronary arteriography using 2
catheters, left ventricular angiography, and found to have arteriosclerotic heart disease.
Pt has no hx of cardiac surgery. What is the proper sequencing of ICD-10-CM and CPT
codes for outpt catheterization? - ✔✔I25.10 (Atherosclerotic heart disease of native
coronary artery without angina pectoris)
93458 (Catheter placement in coronary artery(s) for coronary angiography, incl
intraprocedural injection(s) for coronary angiography, imaging supervision and
interpretation with left heart catheterization including intraprocedural injection(s) for left
ventriculography, when performed
✔✔65yo pt adm w/pain and loosening of left total hip prosthesis along with the
loosening of the acetabular component which has become painful. Pt ad for open
removal/replacement of acetabular component of left hip prosthesis, so what is the
correct coding for admission? - ✔✔T84.031A (mechanical loosening of int lt hip prosth
jt, initial enc
0SPB0JZ (removal synthetic sub fro lt hip jt, open approach
0SRE0JZ (replacement lt hip jt, acetabular surface w/synthetic sub, open approach)
✔✔Maternity pt adm in labor at 43 wks and has normal delivery with vacuum extraction
to facilitate baby's delivery. What is the PD? - ✔✔O48.1 (prolonged pg)
,✔✔With regard to implementation of ICD-10-CM, all of these are correct: - ✔✔ICD-10-
CM was developed by NCHS; it was implemented on 10/1/15; was already being used
by death certificate coding in US; the process of adopting ICD-10-CM is specified in
HIPAA
✔✔What does NCHS stand for? - ✔✔National Center for Health Statistics
✔✔75yo female was adm for AMI and underwent a diagnostic cardiac cath. Following
the cath, pt dev a thrombophlebitis documented as due to the catheter in the common
femoral artery. The thrombophlebitis would be coded as: - ✔✔T81.718A, complication
of other artery following a procedure, NEC, initial enc
✔✔Pt adm to ED w/chest pain, and dx w/abort MI w/acute myocardial ischemia with no
prior cardiac surgery, and normal cardiac enzymes. What is coding for this case? -
✔✔I24.0 (acute coronary thrombosis not resulting in MI) Pts w/acute ischemic heart
disease or acute myocardial ischemia do not always indicate an infarction and it is often
possible to prevent infarction by means of surgery or use of thrombolytic agents if tx
promptly
✔✔Pt has nausea, vomiting, abdominal pain due to acute cholecystitis. Phys doc the
following on DS: Acute cholecystitis, nausea, vomiting, and abdominal pain. What is
correct coding? - ✔✔Acute cholecystitis
✔✔Pt adm bc of CHF, and also found to have elevated liver function tests. Phys worked
up ELF test but able to determine dx, so the following dx is assigned: - ✔✔CHF and
abnormal liver function tests
✔✔Pt adm with hypotension due to dobutamine taken and prescribed correctly. How is
this coded? - ✔✔I95.2, Hypotension due to drugs
T44.5X5A, adverse effects of dobutamine
✔✔Pt adm 2 wks after laminectomy for spinal stenosis w/headache (headache due to
tear in dura accidentally occurred during prior laminectomy surgery). Pt taken to OR for
repair of dura. How is this case coded? - ✔✔G97.41, Accidental puncture or laceration
of dura during procedure
✔✔Pt adm w/SOB, CHF, and subsequently dev resp fail. Pt undergoes intubation
w/ventilator mgmt. Correct seq of dx would be: - ✔✔CHF and resp failure
✔✔Pt adm w/pneumococcal pneumonia and pneumococcal sepsis, so the coder
should: - ✔✔Assign code for sepsis, pneumonia, and severe sepsis. Pt
w/pneumococcal sepsis and pneumococcal pneumonia also has severe sepsis and
,Guidelines provide info related to coding, seq of sepsis, severe sepsis, and localized
infection, such as pneumonia
✔✔Pt adm w/ESRD following kidney transplant, who also had angina and COPD, so dx
would be seq as: - ✔✔ESRD; status post kidney transplant; COPD; angina
✔✔Pt adm to hosp due to fracture of rt hip and scheduled for open reduction with int fix,
but pt dev cardiac arrhythmia which results in an inability to do planned surgery. Assign
code for PD: - ✔✔Rt hip fracture (cond after study that occasioned adm should be seq
first even if the plan of tx was not carried out due to unforeseen circumstances)
✔✔What is not part of a facility coding compliance plan? - ✔✔Coding audits performed
by payers (while this has value, payers are considered external reviewing)
✔✔What are various parts of a facility coding compliance plan? - ✔✔Regular internal
audits, audits performed by objective external reviewers, sharing/discussing results with
coding staff
✔✔In CPT, unlisted codes are reported only if: - ✔✔There is a not a HCPCS level II or a
current CPT level III code available
✔✔A virtual screening colonoscopy would be coded as: - ✔✔74263: Computed
tomographic (CT) colonography, screening including image postprocessing
✔✔Pt underwent excision of malignant lesion of chest measuring 1.0cm with 0.2cm
margin, and based on 2015 CPT codes, which code is used for this procedure? -
✔✔11602, Excision malignant lesion of trunk; excised diameter 1.1-2.0cm
✔✔Pt dx w/L4-5 lumbar neuropathy and discogenic pain. Pt underwent percutaneous
intradiscal electrothermal annuloplasty (IDET) in radiology suite. What ICD-10-PCS
code should be used? - ✔✔0S523ZZ, Destruction, lumbar vertebral disc, percutaneous
(IDET is done w/thermal energy, or heat, directed into the outer disc wall, or annulus,
and inner disc contents, or nucleus, via a heating coil, decreasing pressure inside the
disc
✔✔Laparoscopic tubal ligation with Falope ring is completed, so what is correct CPT
code assignment? - ✔✔58671, Laparoscopy, surgical; with occlusion of oviducts by
device (band, clip, or Falope ring)
✔✔Carcinoma of multiple overlapping sites of the bladder, so dx cystoscopy and
transurethral fulguration of bladder lesions (1.9cm, 6.0 cm) are undertaken. The
appropriate CPT code(s) would be: - ✔✔52240, Cystourethroscopy, with fulguration
(including cryosurgery or laser surgery) and/or resection of lg bladder tumor(s)
, ✔✔Pt presents to facility for upper endoscopy implant of material into muscle of lower
esophageal sphincter, so what is correct coding, seq of pt's record? - ✔✔43236, Upper
gastrointestinal endoscopy including esophagus, stomach, and either the duodenum
and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by
brushing or washing (separate procedure) with directed submucosal injection(s), any
substance
✔✔Pt undergoes colposcopy with endometrial biopsy, so how many codes does is this
case req? - ✔✔Two codes would be used in accordance with 2015 CPT code revisions
✔✔Pt present to outpt surgical area for cystoscopy with mult biopsies of the bladder,
and pt's presenting symptom is hematuria, so what is the correct code assignment this
procedure? - ✔✔52204, Cystourethroscopy with biopsy(s)
✔✔If pt has excision of malignant lesion of the skin, the CPT code is determined by the
body area from which the excision occurs and the: - ✔✔Diameter of lesion as well as
margins excised as described in Op Report
✔✔When coding arthrocentesis, the code assignment is determined by: - ✔✔Size of the
jt since arthrocentesis codes are based on whether jt is small, intermediate, or major
✔✔Assign correct code for open total cholecystectomy with exploration of common bile
duct and removal of common bile duct stone: - ✔✔0FT40ZZ, resection gallbladder,
open approach
0FC90ZZ, removal, common bile duct stone, open
✔✔Assign correct code for total laparoscopic cholecystectomy with percutaneous
removal of common bile duct stone: - ✔✔0FT44ZZ, Resection, gallbladder, Resection of
gallbladder, percutaneous endoscopic approach
0FC94ZZ, Removal, common bile duct stones, laparoscopic
✔✔Assign correct code for total open cholecystectomy with intraoperative
cholangiogram (done w/plain radiography with low osmolar contrast): - ✔✔0FC94ZZ,
Removal, common bile duct stones, laparoscopic
0FT40ZZ, Resection, gallbladder, open approach
✔✔Removal of the entire body part and removal of an entire lobe of the liver is what
root operation? - ✔✔Resection
✔✔Inpt procedures are code with: - ✔✔ICD-10-CM
