CCDS
A. Bleeding gastric ulcer - answerA patient is admitted from the emergency department
(ED) with a diagnosis of weakness and anemia. After admission and further treatment
with packed red blood cells (PRBC), GI consult, and endoscopy, the physician includes
the following diagnoses in the discharge summary: anemia, suspected bleeding gastric
ulcer, and GERD. What would be the most appropriate principle diagnosis?
A. Bleeding gastric ulcer
B. Anemia
C. GERD
D. Weakness
B. Neoplasm of occipital region - answerA patient is admitted with new-onset seizures.
Head CT reveals a mass in the occipital region. The physician documents possible
brain tumor, and the patient is transferred to another hospital for further workup. What
would be the most appropriate principal diagnosis based upon this documentation?
A. Seizure
B. Neoplasm of occipital region
C. Head mass
D. Head tumor
C. 1,2, and 3
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new technology
3. Adjusted based upon number of low-income patients cared for - answerA hospital's
base rate or blended rate is:
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new technology
3. Adjusted based upon number of low-income patients cared for
4. Not adjusted based upon capital expenses
A. 1 and 2
B. 2 and 3
C. 1,2, and 3
D. 1,2,3, and 4
D. Reflect the severity of illness (SOI) and resource consumption of the patient's care -
answerThe final MS-DRG assigned to a patient's medical record should:
,A. Reflect the amount of time the physician spent with the patient
B. Depend upon the patient's length of stay
C. Be assigned by the physician
D. Reflect the severity of illness (SOI) and resource consumption of the patient's care
C. Poisoning - answerA patient is admitted from the emergency department with the
diagnosis of acute respiratory failure due to overdose of pain medication and an
aspiration pneumonia. What is the principal diagnosis?
A. Acute respiratory failure
B. Aspiration pneumonia
C. Poisoning
D. Adverse effect of medication
D. All of the conditions should be coded - answerA patient is admitted with pneumonia,
stage 1 chronic renal failure, chronic anemia, and COPD, While hospitalized the patient
receives IV antibiotics, inhalers, oxygen, IV fluids at 50mL/hr, and iron tablets. Keeping
the guidelines for coding of secondary diagnoses in mind, which condition should be
coded?
A. Pneumonia only
B. Pneumonia and COPD only
C. Pneumonia, COPD, and anemia
D. All of the conditions should be coded
D. Fractured ulna - answerWhich of the following is an example of a hospital-acquired
condition?
A. Fat embolism
B. IV phlebitis
C. Pneumonia
D. Fractured ulna
C. A diagnosis that is listed as possible in the history and physical - answerWhich of the
following is an example of documentation that would meet the present on admission
criteria for coding?
A. A diagnosis that is indicated in the history and physical and ruled out in the discharge
summary
B. A diagnosis found in a previous medical record
C. A diagnosis that is listed as possible in the history and physical
D. An acute condition identified on the third day of admission
A. Colon cancer - answerA patient is admitted with abdominal pain and the history and
physical indicated a diagnosis of probable colon cancer. On day two, the physician
documents acute renal failure in the progress notes and the patient receives IV fluids.
, The discharge summary lists possible metastatic colon cancer and acute renal failure.
The principal diagnosis would be:
A. Colon cancer
B. Acute renal failure
C. Abdominal pain
D. Metastatic neoplasm of the colon
D. 1,2, and 3
1. Include identification of the patient's SOI
2. Identify conditions that are present on admission
3. Support medical necessity - answerAccurate documentation should:
1. Include identification of the patient's SOI
2. Identify conditions that are present on admission
3. Support medical necessity
A. 1 and 2
B. 2 and 3
C. 1 and 3
D. 1,2, and 3
B. Anemia - answerA patient with a history of metastatic lung cancer is directly admitted
from the doctor's office with a diagnosis of anemia secondary to chemotherapy. The
patient receives two units of PRBCs and is discharged. What is the most appropriate
principal diagnosis?
A. Respiratory neoplasm
B. Anemia
C. Admission for chemotherapy
D. Admission for blood transfusion
A. GI hemorrhage - answerA patient is admitted from the ED with rectal bleeding
secondary to Coumadin toxicity. The physician documents that the patient had a recent
increase in Coumadin dosage due to low PT/PTT. The patient also has a history of
COPD and CHF. What is the most appropriate principal diagnosis?
A. GI hemorrhage
B. Coumadin toxicity
C. COPD
D. CHF
C. Infected knee prosthesis - answerA patient comes to the ED with fever, chills, and
knee pain. Documentation states that the patient's admission is for knee prosthesis
A. Bleeding gastric ulcer - answerA patient is admitted from the emergency department
(ED) with a diagnosis of weakness and anemia. After admission and further treatment
with packed red blood cells (PRBC), GI consult, and endoscopy, the physician includes
the following diagnoses in the discharge summary: anemia, suspected bleeding gastric
ulcer, and GERD. What would be the most appropriate principle diagnosis?
A. Bleeding gastric ulcer
B. Anemia
C. GERD
D. Weakness
B. Neoplasm of occipital region - answerA patient is admitted with new-onset seizures.
Head CT reveals a mass in the occipital region. The physician documents possible
brain tumor, and the patient is transferred to another hospital for further workup. What
would be the most appropriate principal diagnosis based upon this documentation?
A. Seizure
B. Neoplasm of occipital region
C. Head mass
D. Head tumor
C. 1,2, and 3
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new technology
3. Adjusted based upon number of low-income patients cared for - answerA hospital's
base rate or blended rate is:
1. Calculated annually
2. Dependent upon indirect costs for graduate medical education and new technology
3. Adjusted based upon number of low-income patients cared for
4. Not adjusted based upon capital expenses
A. 1 and 2
B. 2 and 3
C. 1,2, and 3
D. 1,2,3, and 4
D. Reflect the severity of illness (SOI) and resource consumption of the patient's care -
answerThe final MS-DRG assigned to a patient's medical record should:
,A. Reflect the amount of time the physician spent with the patient
B. Depend upon the patient's length of stay
C. Be assigned by the physician
D. Reflect the severity of illness (SOI) and resource consumption of the patient's care
C. Poisoning - answerA patient is admitted from the emergency department with the
diagnosis of acute respiratory failure due to overdose of pain medication and an
aspiration pneumonia. What is the principal diagnosis?
A. Acute respiratory failure
B. Aspiration pneumonia
C. Poisoning
D. Adverse effect of medication
D. All of the conditions should be coded - answerA patient is admitted with pneumonia,
stage 1 chronic renal failure, chronic anemia, and COPD, While hospitalized the patient
receives IV antibiotics, inhalers, oxygen, IV fluids at 50mL/hr, and iron tablets. Keeping
the guidelines for coding of secondary diagnoses in mind, which condition should be
coded?
A. Pneumonia only
B. Pneumonia and COPD only
C. Pneumonia, COPD, and anemia
D. All of the conditions should be coded
D. Fractured ulna - answerWhich of the following is an example of a hospital-acquired
condition?
A. Fat embolism
B. IV phlebitis
C. Pneumonia
D. Fractured ulna
C. A diagnosis that is listed as possible in the history and physical - answerWhich of the
following is an example of documentation that would meet the present on admission
criteria for coding?
A. A diagnosis that is indicated in the history and physical and ruled out in the discharge
summary
B. A diagnosis found in a previous medical record
C. A diagnosis that is listed as possible in the history and physical
D. An acute condition identified on the third day of admission
A. Colon cancer - answerA patient is admitted with abdominal pain and the history and
physical indicated a diagnosis of probable colon cancer. On day two, the physician
documents acute renal failure in the progress notes and the patient receives IV fluids.
, The discharge summary lists possible metastatic colon cancer and acute renal failure.
The principal diagnosis would be:
A. Colon cancer
B. Acute renal failure
C. Abdominal pain
D. Metastatic neoplasm of the colon
D. 1,2, and 3
1. Include identification of the patient's SOI
2. Identify conditions that are present on admission
3. Support medical necessity - answerAccurate documentation should:
1. Include identification of the patient's SOI
2. Identify conditions that are present on admission
3. Support medical necessity
A. 1 and 2
B. 2 and 3
C. 1 and 3
D. 1,2, and 3
B. Anemia - answerA patient with a history of metastatic lung cancer is directly admitted
from the doctor's office with a diagnosis of anemia secondary to chemotherapy. The
patient receives two units of PRBCs and is discharged. What is the most appropriate
principal diagnosis?
A. Respiratory neoplasm
B. Anemia
C. Admission for chemotherapy
D. Admission for blood transfusion
A. GI hemorrhage - answerA patient is admitted from the ED with rectal bleeding
secondary to Coumadin toxicity. The physician documents that the patient had a recent
increase in Coumadin dosage due to low PT/PTT. The patient also has a history of
COPD and CHF. What is the most appropriate principal diagnosis?
A. GI hemorrhage
B. Coumadin toxicity
C. COPD
D. CHF
C. Infected knee prosthesis - answerA patient comes to the ED with fever, chills, and
knee pain. Documentation states that the patient's admission is for knee prosthesis
