CERTIFIED CODING SPECIALIST
PRACTICE EXAM QUESTIONS AND
VERIFIED SOLUTIONS
Gordon is an 83 year old male patient with type 2 diabetes. He present to the ED with complaints of
increased thirst and blurred vision. Hs blood glucose is checked with a result of 300. His home meds
shoe he has been prescribed 20 mg of Lantus insulin daily. When questioned about taking
medication he responds he has been skipping doses because the cost of filling his too high and that
he also sometimes forgets. He is given IV insulin an dehydration then discharged to home. The final
diagnoses for the ED visit are: Diabetes, uncontrolled secondary to missing prescribed insulin dosage
Senility. What is the correct ICD-10-CM code assignment for this encounter? ✅✅ANSW-E11.65,
T38.3X6A, R41,81, Z79.4, Z91.120, Z91.130
Present on Admission indictors play a role in the determination of
____________________________________. ✅✅ANSW-Hospital acquired conditions (HACs)
Cassidy is coding Mrs. Danielson for treatment of a burn. The history and physical in the health
record include a past medical history of hypertension, but this diagnosis is not included in the final
diagnostic statement. Where can Cassidy look for documentation to support assignment of a code
for hypertension? ✅✅ANSW-Medication history
Which of the following phrases, when found in health record documentations, does not indicate a
cause and effect relationship? ✅✅ANSW-In the context of
The patient is a 56 yr. old female whose diagnoses include balanitis. Which documentation element
is in discrepancy in this scenario? ✅✅ANSW-Gender
When coding for poisonings, adverse effects, toxic effects or underdosing, which of the following are
default designations? ✅✅ANSW-Adverse effect and accidental
Gus is hit by a car and is seen by Dr. Spencer in the ED for an open fracture of the left tibia. To code
this diagnosis to the highest degree of severity the coder should review the documentation for
which clinical numeric value? ✅✅ANSW-Gustillo classification score
Carmela is coding for Mr. Gregorio's inpatient admission. The only diagnosis listed for the visit is
ongoing left sided weakness. Mr. Gregorio's past medical history documents a previous cerebral
, infarction. What is the appropriate coding step for Carmela to take? ✅✅ANSW-Query the
attending physician about a link between the loft sided weakness and the previous cerebral
infarction
Mario was admitted to the hospital for a total hip replacement. The operative report noted blood
loss of 1000 ml. Post-op day 1, Mario developed difficulty breathing and his hemoglobin showed a
drop from 14.2 g/dL to 12.6 g/dL. He was transfused with 1 unit of packed red blood cells. His
discharge diagnoses included OA R hip, CKD stage 3, anemia and hypertension. All chronic conditions
were treated during the admission. What is the query opportunity for this documentation?
✅✅ANSW-Can the type of anemia be further specified?
Trina is a 64 yr. old female patient who was admitted with chest pain and dyspnea after falling into a
polluted river. His chest x-ray shows free fluid on the basal segments of both lungs and analysis of
her sputum notes the presence of petroleum products. The pulmonology consultation lists a
diagnosis of aspiration pneumonia. The discharge diagnosis on the attending physician's discharge
summary states only, pneumonia. Which of the following is a complaint query based on this
documentation? ✅✅ANSW-Your discharge summary documents a diagnosis of pneumonia.
Based on the clinical indicators presented, can the etiology of the patient's pneumonia be further
specified as aspiration pneumonia?
Bart is a 56 yr. old male known dysphagia and witnessed aspiration. He develops cough, chest
discomfort and fever and is admitted for evaluation. His final diagnosis is "pneumonia". Which of the
following is an appropriate non-leading query based on these clinical indicators? ✅✅ANSW-Your
discharge summary documents a diagnosis of pneumonia. Based on the clinical factors presented,
can the etiology of the patient's pneumonia be further specified?
Minerva was admitted to ABC Hospital for difficulty breathing and edema in her legs. Her comorbid
conditions included hypertension, diabetes, chronic renal failure, hyperlipidemia and a stage 3
pressure ulcer of the right buttock. During her stay she had an echocardiogram that indicated
congestive heart failure with preserved ejection fraction. All of her chronic conditions were treated
and she had debridement of her pressure ulcer down to the muscle. Her discharge diagnoses were
listed as: congestive heart failure, hypertension, diabetes, chronic renal failure stage II,
hyperlipidemia, stage 3 pressure ulcer of right buttock status post debridement. What is the query
opportunity for this admission? ✅✅ANSW-The type of debridement
A covered entity may deny a patient's request to
______________________________________________________. ✅✅ANSW-Restrict uses and
disclosures of their PHI
PRACTICE EXAM QUESTIONS AND
VERIFIED SOLUTIONS
Gordon is an 83 year old male patient with type 2 diabetes. He present to the ED with complaints of
increased thirst and blurred vision. Hs blood glucose is checked with a result of 300. His home meds
shoe he has been prescribed 20 mg of Lantus insulin daily. When questioned about taking
medication he responds he has been skipping doses because the cost of filling his too high and that
he also sometimes forgets. He is given IV insulin an dehydration then discharged to home. The final
diagnoses for the ED visit are: Diabetes, uncontrolled secondary to missing prescribed insulin dosage
Senility. What is the correct ICD-10-CM code assignment for this encounter? ✅✅ANSW-E11.65,
T38.3X6A, R41,81, Z79.4, Z91.120, Z91.130
Present on Admission indictors play a role in the determination of
____________________________________. ✅✅ANSW-Hospital acquired conditions (HACs)
Cassidy is coding Mrs. Danielson for treatment of a burn. The history and physical in the health
record include a past medical history of hypertension, but this diagnosis is not included in the final
diagnostic statement. Where can Cassidy look for documentation to support assignment of a code
for hypertension? ✅✅ANSW-Medication history
Which of the following phrases, when found in health record documentations, does not indicate a
cause and effect relationship? ✅✅ANSW-In the context of
The patient is a 56 yr. old female whose diagnoses include balanitis. Which documentation element
is in discrepancy in this scenario? ✅✅ANSW-Gender
When coding for poisonings, adverse effects, toxic effects or underdosing, which of the following are
default designations? ✅✅ANSW-Adverse effect and accidental
Gus is hit by a car and is seen by Dr. Spencer in the ED for an open fracture of the left tibia. To code
this diagnosis to the highest degree of severity the coder should review the documentation for
which clinical numeric value? ✅✅ANSW-Gustillo classification score
Carmela is coding for Mr. Gregorio's inpatient admission. The only diagnosis listed for the visit is
ongoing left sided weakness. Mr. Gregorio's past medical history documents a previous cerebral
, infarction. What is the appropriate coding step for Carmela to take? ✅✅ANSW-Query the
attending physician about a link between the loft sided weakness and the previous cerebral
infarction
Mario was admitted to the hospital for a total hip replacement. The operative report noted blood
loss of 1000 ml. Post-op day 1, Mario developed difficulty breathing and his hemoglobin showed a
drop from 14.2 g/dL to 12.6 g/dL. He was transfused with 1 unit of packed red blood cells. His
discharge diagnoses included OA R hip, CKD stage 3, anemia and hypertension. All chronic conditions
were treated during the admission. What is the query opportunity for this documentation?
✅✅ANSW-Can the type of anemia be further specified?
Trina is a 64 yr. old female patient who was admitted with chest pain and dyspnea after falling into a
polluted river. His chest x-ray shows free fluid on the basal segments of both lungs and analysis of
her sputum notes the presence of petroleum products. The pulmonology consultation lists a
diagnosis of aspiration pneumonia. The discharge diagnosis on the attending physician's discharge
summary states only, pneumonia. Which of the following is a complaint query based on this
documentation? ✅✅ANSW-Your discharge summary documents a diagnosis of pneumonia.
Based on the clinical indicators presented, can the etiology of the patient's pneumonia be further
specified as aspiration pneumonia?
Bart is a 56 yr. old male known dysphagia and witnessed aspiration. He develops cough, chest
discomfort and fever and is admitted for evaluation. His final diagnosis is "pneumonia". Which of the
following is an appropriate non-leading query based on these clinical indicators? ✅✅ANSW-Your
discharge summary documents a diagnosis of pneumonia. Based on the clinical factors presented,
can the etiology of the patient's pneumonia be further specified?
Minerva was admitted to ABC Hospital for difficulty breathing and edema in her legs. Her comorbid
conditions included hypertension, diabetes, chronic renal failure, hyperlipidemia and a stage 3
pressure ulcer of the right buttock. During her stay she had an echocardiogram that indicated
congestive heart failure with preserved ejection fraction. All of her chronic conditions were treated
and she had debridement of her pressure ulcer down to the muscle. Her discharge diagnoses were
listed as: congestive heart failure, hypertension, diabetes, chronic renal failure stage II,
hyperlipidemia, stage 3 pressure ulcer of right buttock status post debridement. What is the query
opportunity for this admission? ✅✅ANSW-The type of debridement
A covered entity may deny a patient's request to
______________________________________________________. ✅✅ANSW-Restrict uses and
disclosures of their PHI
