CERTIFIED CODING SPECIALIST
QUESTIONS AND VERIFIED
SOLUTIONS
A patient is diagnosed with infertility due to endometriosis and undergoes an outpatient
laparoscopic laser destruction of pelvic endometriosis. In order to code this encounter accurately,
what steps must the coder take? ✅✅ANSW-d. Review the operative report to determine what
procedure codes to use. Determine the site or sites of endometriosis so codes with the highest
specificity may be assigned. Assign endometriosis as the principal diagnosis. Assign infertility as a
secondary condition.
In order to accurately code a cardiac catheterization, in addition to the approach and the side of the
heart into which the catheter was inserted, what else needs to be determined?
a. The type of anaesthesia used
b. If additional procedures were performed
c. The duration of the procedure
d. Documentation that stents were considered ✅✅ANSW-b. If additional procedure were
performed
A female patient is admitted for a second-degree cystocele. A repair is performed. Which report
provides the documentation necessary to accurately code the repair?
a. History and physical
b. Discharge summary
c. Consultation
d. Operative report ✅✅ANSW-d. Operative report
To accurately report wound closures with CPT codes, in addition to knowing the side and length of
the closure, what other information is necessary?
a. If anesthesia was used and what kind
b. The repair type: simple, intermediate, or complex
c. The supplies that were used
d. If exploration of tendons or blood vessels occurred ✅✅ANSW-b. the repair type
, Multiple choice queries must supply how many choices in order to be compliant?
a. 3
b. 4
c. 5
d. No specific number ✅✅ANSW-d. No specific number
Compliant queries include which of the following?
a. Comparison of reimbursement amounts
b. Relevant clinical indicators
c. Potential impact on quality scores
d. Impact on physician licensure ✅✅ANSW-b. Relevant clinical indicators
Which of the following makes a query compliant?
a. Keeping the question vague so the physician has an opportunity to use his discretion when
responding
b. Explaining why the requested diagnosis is necessary to achieve a higher reimbursement
c. Addressing the impact the query has on quality indicators
d. Providing a concise presentation of facts and clinical indicators ✅✅ANSW-d. Providing a
concise presentation of facts and clinical indicators
A patient was admitted with heart failure within one week of a heart transplant. Due to the timing,
the coder thought the heart failure may indicate a transplant rejection. What actions should the
coding staff take?
a. Query the physician
b. Assign the codes for the transplant rejection and the heart failure
c. Assign only the code for the transplant rejection
d. Assign only the code for the heart failure ✅✅ANSW-a. Query the physican
A patient had a normal pregnancy and delivery with loose nuchal cord around neck. Delivery was
accompanied by an episotomy with repair with the birth of the liveborn male infant. Delivery room
record states "no evidence of fetal problem." What is the query opportunity for this record?
✅✅ANSW-b. Weeks of gestation/trimester
QUESTIONS AND VERIFIED
SOLUTIONS
A patient is diagnosed with infertility due to endometriosis and undergoes an outpatient
laparoscopic laser destruction of pelvic endometriosis. In order to code this encounter accurately,
what steps must the coder take? ✅✅ANSW-d. Review the operative report to determine what
procedure codes to use. Determine the site or sites of endometriosis so codes with the highest
specificity may be assigned. Assign endometriosis as the principal diagnosis. Assign infertility as a
secondary condition.
In order to accurately code a cardiac catheterization, in addition to the approach and the side of the
heart into which the catheter was inserted, what else needs to be determined?
a. The type of anaesthesia used
b. If additional procedures were performed
c. The duration of the procedure
d. Documentation that stents were considered ✅✅ANSW-b. If additional procedure were
performed
A female patient is admitted for a second-degree cystocele. A repair is performed. Which report
provides the documentation necessary to accurately code the repair?
a. History and physical
b. Discharge summary
c. Consultation
d. Operative report ✅✅ANSW-d. Operative report
To accurately report wound closures with CPT codes, in addition to knowing the side and length of
the closure, what other information is necessary?
a. If anesthesia was used and what kind
b. The repair type: simple, intermediate, or complex
c. The supplies that were used
d. If exploration of tendons or blood vessels occurred ✅✅ANSW-b. the repair type
, Multiple choice queries must supply how many choices in order to be compliant?
a. 3
b. 4
c. 5
d. No specific number ✅✅ANSW-d. No specific number
Compliant queries include which of the following?
a. Comparison of reimbursement amounts
b. Relevant clinical indicators
c. Potential impact on quality scores
d. Impact on physician licensure ✅✅ANSW-b. Relevant clinical indicators
Which of the following makes a query compliant?
a. Keeping the question vague so the physician has an opportunity to use his discretion when
responding
b. Explaining why the requested diagnosis is necessary to achieve a higher reimbursement
c. Addressing the impact the query has on quality indicators
d. Providing a concise presentation of facts and clinical indicators ✅✅ANSW-d. Providing a
concise presentation of facts and clinical indicators
A patient was admitted with heart failure within one week of a heart transplant. Due to the timing,
the coder thought the heart failure may indicate a transplant rejection. What actions should the
coding staff take?
a. Query the physician
b. Assign the codes for the transplant rejection and the heart failure
c. Assign only the code for the transplant rejection
d. Assign only the code for the heart failure ✅✅ANSW-a. Query the physican
A patient had a normal pregnancy and delivery with loose nuchal cord around neck. Delivery was
accompanied by an episotomy with repair with the birth of the liveborn male infant. Delivery room
record states "no evidence of fetal problem." What is the query opportunity for this record?
✅✅ANSW-b. Weeks of gestation/trimester
