Certified Coding Specialist (CCS) Exam Prep Questions -AHIMA
6th Edition with Answers
Carcinoma in situ - ANSWER -Tumor cells (HHS 2014, Section II.A., 98).
that are undergoing malignant changes but are
still confined to the point of origin without
invasion of the surrounding normal tissue A patient was admitted with heart failure within
one week of a heart transplant. Due to the timing,
the coder thought that it may represent a
Examples of carcinoma in situ - ANSWER - postoperative transplant rejection following heart
Intraepithelial infiltrating transplant.
What action(s) should the coding staff take?
The patient was admitted from the emergency a. Query the physician.
department because of chest pain. Following b. Assign the codes for the postoperative
blood work, it was determined that the patient transplant rejection.
had elevated CPKs and MB enzymes. The EKG c. Assign only the code for the transplant
shows nonspecific ST changes. rejection.
d. Assign only the code for heart failure. -
What type of diagnosis might this indicate? ANSWER -a
a. Unstable angina
b. Myocardial infarction When the documentation is not clear regarding a
c. Congestive heart failure potential complication, it is appropriate query the
d. Mitral valve stenosis - ANSWER -b physician (HHS 2014, Section I.B.16, 16; Leon-
The CPK elevation with MB enzymes elevated Chisen 2013, 43-44).
and the EKG ST changes denote a possible Ml
(Leon-Chisen 2013, 386-387).
A patient is admitted to a psychiatric unit of an
acute-care facility. The patient experienced the
A patient is admitted and diagnosed with fever following symptoms almost every day for the last
and urinary burning. The discharge diagnosis· is month: loss of interest or pleasure in most or all
Escherichia coli, urinary tract infection. activities, which is a change from her prior level
of functioning. She has also gained 15 lbs, has
Which of the following represents the correct difficulty falling asleep, feels fatigued, and has
diagnoses and appropriate sequence of those difficulty making decisions.
conditions?
a. Fever, urinary burning, urosepsis What potential diagnosis most closely fits the
b. Fever, urinary burning, sepsis patient's overall symptoms?
c. Escherichia coli, urinary tract infection a. Insomnia
d. Urinary tract infection, Escherichia coli - b. Major depression
c. Reye's syndrome
ANSWER -d
Symptoms are not coded when a definitive d. Bipolar disorder - ANSWER -b
diagnosis is present on discharge. The patient
discharge diagnosis of urinary tract infection. The The symptoms provided are indicative of a
organism (E. coli) is coded with a seco diagnosis depressive disorder (Leon-Chisen 2013, 175).
code (B96.20) which is to be added as an
additional code to identify the bacterial agent
Inpatient:
, Certified Coding Specialist (CCS) Exam Prep Questions -AHIMA
6th Edition with Answers
Admission for inguinal hernia repair. This 30- patient also had tic douloureux. -
year-old patient has acquired immunodeficiency ANSWER -ICD-10-CM: G40.909, G50.0
syndrome (AIDS) but is not symptomatic at this
time due to medication regimen. The procedure (Schraffenberger 2013,158-159).
performed was a right indirect inguinal
herniorrhaphy via open approach. -
ANSWER -ICD-10-CM: K40.90, B20, Inpatient:
ICD-10-PCS: OYQ50ZZ (Schraffenberger 2013, A patient was admitted to an acute care facility
82-84,252) with a temperature of 102 and atrial fibrillation.
The chest x-ray reveals pneumonia with
subsequent documentation by the physician of
Inpatient: pneumonia in the progress notes and discharge
summary. The patient was treated with oral
A 75-year-old male patient was admitted from a antiarrhythmia medications and IV antibiotics. -
nursing home with dehydration and dysphagia ANSWER -ICD-10-CM: J18.9, 148.91-
due to a previous stroke. During hospitalization
the patient was rehydrated and transferred back In accordance with the UHDDS, both conditions
to the nursing home. - ANSWER -ICD-10- are not equally treated. The pneumonia was
CM: E86.0, I69.391 treated with IV antibiotics. This diagnosis had
greater utilization of resources of medications
(Schraffenberger 2013, 131, 209-210). and staff time compared with the atrial fibrillation,
Stroke= cerebral infarction which was treated with oral medication. Because
of this, the pneumonia is sequenced first (HHS
2014, Section II, C).
Inpatient:
A patient is admitted to an acute care facility for Inpatient:
detoxification from alcohol and barbiturate
intoxication with chronic alcoholism and A patient with chronic cholecystitis and
barbiturate abuse. The patient also has cirrhosis gallbladder stones underwent a laparoscopic
of the liver due to alcoholism. - ANSWER - cholecystectomy in an acute care facility.
ICD-10-CM: F10.229, F13.129, K70.30, However, due to extensive gallbladder adhesions
the procedure was converted to an open
(Schraffenberger 2013, 140-143.) cholecystectomy. - ANSWER -ICD-10-CM:
K80.10, K82.8 (Schraffenberger 2013, 249-250,
ICD-10-PCS HZ2ZZZZ 454); HHS 2011, Section I, 18. d, 14), ICD-10-
PCS: OFT40ZZ, OFJ44ZZ (Leon-Chisen 2014,
(Leon-Chisen 2014, 186). 250).
Inpatient: Inpatient:
A 30-year-old patient was seen in the emergency A patient is admitted to the inpatient setting with
department for recurrent epileptic seizures. The hydronephrosis and a staghorn calculus of the
6th Edition with Answers
Carcinoma in situ - ANSWER -Tumor cells (HHS 2014, Section II.A., 98).
that are undergoing malignant changes but are
still confined to the point of origin without
invasion of the surrounding normal tissue A patient was admitted with heart failure within
one week of a heart transplant. Due to the timing,
the coder thought that it may represent a
Examples of carcinoma in situ - ANSWER - postoperative transplant rejection following heart
Intraepithelial infiltrating transplant.
What action(s) should the coding staff take?
The patient was admitted from the emergency a. Query the physician.
department because of chest pain. Following b. Assign the codes for the postoperative
blood work, it was determined that the patient transplant rejection.
had elevated CPKs and MB enzymes. The EKG c. Assign only the code for the transplant
shows nonspecific ST changes. rejection.
d. Assign only the code for heart failure. -
What type of diagnosis might this indicate? ANSWER -a
a. Unstable angina
b. Myocardial infarction When the documentation is not clear regarding a
c. Congestive heart failure potential complication, it is appropriate query the
d. Mitral valve stenosis - ANSWER -b physician (HHS 2014, Section I.B.16, 16; Leon-
The CPK elevation with MB enzymes elevated Chisen 2013, 43-44).
and the EKG ST changes denote a possible Ml
(Leon-Chisen 2013, 386-387).
A patient is admitted to a psychiatric unit of an
acute-care facility. The patient experienced the
A patient is admitted and diagnosed with fever following symptoms almost every day for the last
and urinary burning. The discharge diagnosis· is month: loss of interest or pleasure in most or all
Escherichia coli, urinary tract infection. activities, which is a change from her prior level
of functioning. She has also gained 15 lbs, has
Which of the following represents the correct difficulty falling asleep, feels fatigued, and has
diagnoses and appropriate sequence of those difficulty making decisions.
conditions?
a. Fever, urinary burning, urosepsis What potential diagnosis most closely fits the
b. Fever, urinary burning, sepsis patient's overall symptoms?
c. Escherichia coli, urinary tract infection a. Insomnia
d. Urinary tract infection, Escherichia coli - b. Major depression
c. Reye's syndrome
ANSWER -d
Symptoms are not coded when a definitive d. Bipolar disorder - ANSWER -b
diagnosis is present on discharge. The patient
discharge diagnosis of urinary tract infection. The The symptoms provided are indicative of a
organism (E. coli) is coded with a seco diagnosis depressive disorder (Leon-Chisen 2013, 175).
code (B96.20) which is to be added as an
additional code to identify the bacterial agent
Inpatient:
, Certified Coding Specialist (CCS) Exam Prep Questions -AHIMA
6th Edition with Answers
Admission for inguinal hernia repair. This 30- patient also had tic douloureux. -
year-old patient has acquired immunodeficiency ANSWER -ICD-10-CM: G40.909, G50.0
syndrome (AIDS) but is not symptomatic at this
time due to medication regimen. The procedure (Schraffenberger 2013,158-159).
performed was a right indirect inguinal
herniorrhaphy via open approach. -
ANSWER -ICD-10-CM: K40.90, B20, Inpatient:
ICD-10-PCS: OYQ50ZZ (Schraffenberger 2013, A patient was admitted to an acute care facility
82-84,252) with a temperature of 102 and atrial fibrillation.
The chest x-ray reveals pneumonia with
subsequent documentation by the physician of
Inpatient: pneumonia in the progress notes and discharge
summary. The patient was treated with oral
A 75-year-old male patient was admitted from a antiarrhythmia medications and IV antibiotics. -
nursing home with dehydration and dysphagia ANSWER -ICD-10-CM: J18.9, 148.91-
due to a previous stroke. During hospitalization
the patient was rehydrated and transferred back In accordance with the UHDDS, both conditions
to the nursing home. - ANSWER -ICD-10- are not equally treated. The pneumonia was
CM: E86.0, I69.391 treated with IV antibiotics. This diagnosis had
greater utilization of resources of medications
(Schraffenberger 2013, 131, 209-210). and staff time compared with the atrial fibrillation,
Stroke= cerebral infarction which was treated with oral medication. Because
of this, the pneumonia is sequenced first (HHS
2014, Section II, C).
Inpatient:
A patient is admitted to an acute care facility for Inpatient:
detoxification from alcohol and barbiturate
intoxication with chronic alcoholism and A patient with chronic cholecystitis and
barbiturate abuse. The patient also has cirrhosis gallbladder stones underwent a laparoscopic
of the liver due to alcoholism. - ANSWER - cholecystectomy in an acute care facility.
ICD-10-CM: F10.229, F13.129, K70.30, However, due to extensive gallbladder adhesions
the procedure was converted to an open
(Schraffenberger 2013, 140-143.) cholecystectomy. - ANSWER -ICD-10-CM:
K80.10, K82.8 (Schraffenberger 2013, 249-250,
ICD-10-PCS HZ2ZZZZ 454); HHS 2011, Section I, 18. d, 14), ICD-10-
PCS: OFT40ZZ, OFJ44ZZ (Leon-Chisen 2014,
(Leon-Chisen 2014, 186). 250).
Inpatient: Inpatient:
A 30-year-old patient was seen in the emergency A patient is admitted to the inpatient setting with
department for recurrent epileptic seizures. The hydronephrosis and a staghorn calculus of the
