Certified Coding Specialist (CCS®) Exam |
Complete Certified Questions and Correct Verified
Answers | 2025/2026 Edition
Comprehensive AHIMA CCS® Exam Review | 2025/2026 Updated Edition | Includes the
complete set of actual exam-style questions with correct, verified answers and in-depth
explanations | Covers all CCS® exam domains: Diagnosis and Procedure Coding (ICD-10-CM,
ICD-10-PCS, CPT/HCPCS Level II), Reimbursement Methodologies, Compliance, Data Quality,
Confidentiality, Privacy, and Information Governance.
Introduction
This document contains the fully updated Certified Coding Specialist (CCS®) exam questions
and answers for the 2025/2026 testing cycle. All answers are verified as correct, with detailed
rationales aligned with ICD-10-CM/PCS Official Guidelines, CPT®/HCPCS Level II standards,
AHIMA compliance protocols, HIPAA regulations, and real-world inpatient and outpatient
coding scenarios.
Answer Format
Each question is directly followed by the correct answer in bold green, supported by a clear
explanation, coding rationale, and references from authoritative sources such as the Official
Coding Guidelines, AHIMA practice briefs, and CMS regulations.
1. A patient is admitted with acute myocardial infarction (AMI) of the
anterior wall, initial episode. What is the correct ICD-10-CM code?
a) I21.09
b) I21.3
c) I21.01
d) I22.0
c) I21.01
Rationale: I21.01 is the ICD-10-CM code for ST elevation (STEMI) myocardial infarction
involving the left main or anterior wall, initial episode, per ICD-10-CM Official Guidelines
(Section I.C.9.e).
Domain: Diagnosis Coding
Example: Coding AMI for a patient with chest pain and ECG showing anterior wall STEMI.
Test-Taking Tip: Verify the site and episode for AMI coding.
2. A patient undergoes an open cholecystectomy. What is the correct
ICD-10-PCS code?
a) 0FT44ZZ
,b) 0FT40ZZ
c) 0FB44ZZ
d) 0FT48ZZ
b) 0FT40ZZ
Rationale: 0FT40ZZ is the ICD-10-PCS code for resection of the gallbladder (cholecystectomy)
via open approach, per ICD-10-PCS Official Guidelines.
Domain: Procedure Coding
Example: Coding an open cholecystectomy for gallstones.
Test-Taking Tip: Confirm the root operation (resection) and approach for ICD-10-PCS.
3. A physician performs an office visit with a detailed history, detailed
exam, and low-complexity medical decision-making. What is the correct
CPT® code?
a) 99212
b) 99213
c) 99214
d) 99215
b) 99213
Rationale: CPT® 99213 is appropriate for an established patient office visit with a detailed
history, detailed exam, and low-complexity medical decision-making, per AMA CPT®
guidelines.
Domain: Procedure Coding
Example: Coding an office visit for a patient with hypertension follow-up.
Test-Taking Tip: Match E/M components to the correct CPT® code.
4. What is the purpose of a coding compliance audit in a healthcare
organization?
a) To schedule patient procedures
b) To ensure accurate and compliant coding
c) To document clinical outcomes
d) To audit hospital finances
b) To ensure accurate and compliant coding
Rationale: Coding compliance audits ensure coding accuracy and adherence to regulations, per
AHIMA’s Coding Compliance Guidelines and OIG standards.
Domain: Compliance
Example: Auditing charts to verify ICD-10-CM and CPT® code accuracy.
Test-Taking Tip: Focus on compliance in coding audits.
5. A patient is diagnosed with type 2 diabetes with neuropathy. What is the
correct ICD-10-CM code?
a) E10.40
b) E11.40
c) E11.9
d) E10.9
b) E11.40
, Rationale: E11.40 is the ICD-10-CM code for type 2 diabetes mellitus with diabetic neuropathy,
per ICD-10-CM Official Guidelines (Section I.C.4).
Domain: Diagnosis Coding
Example: Coding diabetes with neuropathy for a patient with numbness.
Test-Taking Tip: Use combination codes for diabetes complications.
6. A patient undergoes a colonoscopy with polypectomy. What is the correct
CPT® code?
a) 45378
b) 45380
c) 45385
d) 45384
c) 45385
Rationale: CPT® 45385 is for a colonoscopy with polypectomy using snare technique, per AMA
CPT® guidelines.
Domain: Procedure Coding
Example: Coding a colonoscopy with removal of a polyp via snare.
Test-Taking Tip: Verify the specific technique for colonoscopy coding.
7. What is the purpose of the MS-DRG system in inpatient reimbursement?
a) To schedule patient procedures
b) To group patients for payment based on diagnoses and procedures
c) To document clinical outcomes
d) To audit hospital finances
b) To group patients for payment based on diagnoses and procedures
Rationale: The MS-DRG system groups patients for inpatient reimbursement based on
diagnoses and procedures, per CMS guidelines.
Domain: Reimbursement Methodologies
Example: Assigning MS-DRG 291 for heart failure with MCC.
Test-Taking Tip: MS-DRGs drive inpatient reimbursement.
8. A patient is admitted with pneumonia due to Streptococcus pneumoniae.
What is the correct ICD-10-CM code?
a) J18.9
b) J13
c) J15.4
d) J14
b) J13
Rationale: J13 is the ICD-10-CM code for pneumonia due to Streptococcus pneumoniae, per
ICD-10-CM Official Guidelines (Section I.C.10).
Domain: Diagnosis Coding
Example: Coding pneumonia with a positive Streptococcus culture.
Test-Taking Tip: Use organism-specific codes when documented.
9. A patient undergoes a percutaneous coronary angioplasty with stent
placement. What is the correct ICD-10-PCS code?
Complete Certified Questions and Correct Verified
Answers | 2025/2026 Edition
Comprehensive AHIMA CCS® Exam Review | 2025/2026 Updated Edition | Includes the
complete set of actual exam-style questions with correct, verified answers and in-depth
explanations | Covers all CCS® exam domains: Diagnosis and Procedure Coding (ICD-10-CM,
ICD-10-PCS, CPT/HCPCS Level II), Reimbursement Methodologies, Compliance, Data Quality,
Confidentiality, Privacy, and Information Governance.
Introduction
This document contains the fully updated Certified Coding Specialist (CCS®) exam questions
and answers for the 2025/2026 testing cycle. All answers are verified as correct, with detailed
rationales aligned with ICD-10-CM/PCS Official Guidelines, CPT®/HCPCS Level II standards,
AHIMA compliance protocols, HIPAA regulations, and real-world inpatient and outpatient
coding scenarios.
Answer Format
Each question is directly followed by the correct answer in bold green, supported by a clear
explanation, coding rationale, and references from authoritative sources such as the Official
Coding Guidelines, AHIMA practice briefs, and CMS regulations.
1. A patient is admitted with acute myocardial infarction (AMI) of the
anterior wall, initial episode. What is the correct ICD-10-CM code?
a) I21.09
b) I21.3
c) I21.01
d) I22.0
c) I21.01
Rationale: I21.01 is the ICD-10-CM code for ST elevation (STEMI) myocardial infarction
involving the left main or anterior wall, initial episode, per ICD-10-CM Official Guidelines
(Section I.C.9.e).
Domain: Diagnosis Coding
Example: Coding AMI for a patient with chest pain and ECG showing anterior wall STEMI.
Test-Taking Tip: Verify the site and episode for AMI coding.
2. A patient undergoes an open cholecystectomy. What is the correct
ICD-10-PCS code?
a) 0FT44ZZ
,b) 0FT40ZZ
c) 0FB44ZZ
d) 0FT48ZZ
b) 0FT40ZZ
Rationale: 0FT40ZZ is the ICD-10-PCS code for resection of the gallbladder (cholecystectomy)
via open approach, per ICD-10-PCS Official Guidelines.
Domain: Procedure Coding
Example: Coding an open cholecystectomy for gallstones.
Test-Taking Tip: Confirm the root operation (resection) and approach for ICD-10-PCS.
3. A physician performs an office visit with a detailed history, detailed
exam, and low-complexity medical decision-making. What is the correct
CPT® code?
a) 99212
b) 99213
c) 99214
d) 99215
b) 99213
Rationale: CPT® 99213 is appropriate for an established patient office visit with a detailed
history, detailed exam, and low-complexity medical decision-making, per AMA CPT®
guidelines.
Domain: Procedure Coding
Example: Coding an office visit for a patient with hypertension follow-up.
Test-Taking Tip: Match E/M components to the correct CPT® code.
4. What is the purpose of a coding compliance audit in a healthcare
organization?
a) To schedule patient procedures
b) To ensure accurate and compliant coding
c) To document clinical outcomes
d) To audit hospital finances
b) To ensure accurate and compliant coding
Rationale: Coding compliance audits ensure coding accuracy and adherence to regulations, per
AHIMA’s Coding Compliance Guidelines and OIG standards.
Domain: Compliance
Example: Auditing charts to verify ICD-10-CM and CPT® code accuracy.
Test-Taking Tip: Focus on compliance in coding audits.
5. A patient is diagnosed with type 2 diabetes with neuropathy. What is the
correct ICD-10-CM code?
a) E10.40
b) E11.40
c) E11.9
d) E10.9
b) E11.40
, Rationale: E11.40 is the ICD-10-CM code for type 2 diabetes mellitus with diabetic neuropathy,
per ICD-10-CM Official Guidelines (Section I.C.4).
Domain: Diagnosis Coding
Example: Coding diabetes with neuropathy for a patient with numbness.
Test-Taking Tip: Use combination codes for diabetes complications.
6. A patient undergoes a colonoscopy with polypectomy. What is the correct
CPT® code?
a) 45378
b) 45380
c) 45385
d) 45384
c) 45385
Rationale: CPT® 45385 is for a colonoscopy with polypectomy using snare technique, per AMA
CPT® guidelines.
Domain: Procedure Coding
Example: Coding a colonoscopy with removal of a polyp via snare.
Test-Taking Tip: Verify the specific technique for colonoscopy coding.
7. What is the purpose of the MS-DRG system in inpatient reimbursement?
a) To schedule patient procedures
b) To group patients for payment based on diagnoses and procedures
c) To document clinical outcomes
d) To audit hospital finances
b) To group patients for payment based on diagnoses and procedures
Rationale: The MS-DRG system groups patients for inpatient reimbursement based on
diagnoses and procedures, per CMS guidelines.
Domain: Reimbursement Methodologies
Example: Assigning MS-DRG 291 for heart failure with MCC.
Test-Taking Tip: MS-DRGs drive inpatient reimbursement.
8. A patient is admitted with pneumonia due to Streptococcus pneumoniae.
What is the correct ICD-10-CM code?
a) J18.9
b) J13
c) J15.4
d) J14
b) J13
Rationale: J13 is the ICD-10-CM code for pneumonia due to Streptococcus pneumoniae, per
ICD-10-CM Official Guidelines (Section I.C.10).
Domain: Diagnosis Coding
Example: Coding pneumonia with a positive Streptococcus culture.
Test-Taking Tip: Use organism-specific codes when documented.
9. A patient undergoes a percutaneous coronary angioplasty with stent
placement. What is the correct ICD-10-PCS code?
