CCS Exam prep – EXAM 1 2026 -
2027 ACTUAL EXAM 2026| ALL
QUESTIONS AND CORRECT
ANSWERS | ALREADY GRADED A+ |
VERIFIED ANSWERS | LATEST
VERSION (JUST RELEASED)
According to the UHDDS, in order to assign a code for
another diagnosis, documentation must be present that:
a. The condition is recorded in the patient record by a dietary
clerk
b. The condition is present in the admission department data
c. The condition was clinically evaluated or therapeutically
treated, extended the length of hospital stay, or increased
nursing care or monitoring
d. The condition is considered to be essential by the family
Correct Answer: C
For reporting purposes the definition for other
diagnoses is interpreted as additional conditions that
affect patient care in terms of requiring: clinical evaluation;
or therapeutic treatment; or diagnostic procedures; or
extended length of hospital stay; or increased
nursing care or monitoring (CMS 2018a, Section III, 105-106).
,Most hospitals require a medical record is completed
within:
a. 5 days
b. 10 days
c. 7 days
d. 30 days
Correct Answer: D
The Medicare Conditions of Participation and the Joint
Commission require that the medical record is completed
no later than 30 days following discharge of the patient
(Brickner 2016, 84).
Infusion of Herceptin, a monoclonal antibody used for
treatment of breast cancer in patients carrying a certain
mutation of the HER2 gene, is classified as:
a. Chemotherapy
b. Radiotherapy
c. Molecular Targets
d. Immunotherapy
Correct Answer: C
Targeted cancer therapies are drugs or other substances
that block the growth and spread of cancer by interfering
with specific molecules involved in tumor growth and
,progression.
Herceptin is a type of targeted cancer therapy also referred
to as a monoclonal antibody (National Cancer Institute
2018).
A patient has findings suggestive of chronic obstructive
pulmonary disease (COPD) on chest x-ray. The attending
physician mentions the x-ray finding in one progress note
but no medication, treatment, or further evaluation is
provided. The coder should:
a. Query the attending physician regarding the x-ray finding
b. Code the condition because the documentation reflects it
c. Question the radiologist regarding whether to code this
condition
d. Use a code from abnormal findings to reflect the condition
Correct Answer: A
Query the attending physician regarding the clinical
significance of the findings and request that appropriate
documentation be provided. This is an example of a
circumstance where the chronic condition must be
verified. All secondary conditions must meet the
UHDDS definitions; it is not clear if COPD does (CMS 2018a,
Section III, 105-106).
, If a patient undergoes an inpatient procedure and the final
summary diagnosis is different from the diagnosis on the
pathology report, the coder should:
a. Code only from the discharge diagnoses
b. Code the diagnosis reflected on the pathology report
c. Code the most severe symptom
d. Query the attending physician as to the final diagnosis
Correct Answer: D
Coding strictly from the pathology report is not
appropriate as the coder is assigning a diagnosis without
the attending physician's corroboration. It is therefore
appropriate to query the physician (CMS 2018a, Section
III, 105-106).
A 56-year-old woman is admitted to an acute-care facility
from a skilled nursing facility. The patient has multiple
sclerosis and hypertension. During the course of
hospitalization, a decubitus ulcer is found and debrided at
the bedside by a physician. There is no typed
operative report and no pathology report. The coder should:
a. Use an excisional debridement code as these charts are
rarely reviewed to verify the excisional debridement
b. Code with a nonexcisional debridement procedure code
c. Query the healthcare provider who performed the
procedure to determine if the debridement was
excisional
d. Eliminate the procedure code all together
2027 ACTUAL EXAM 2026| ALL
QUESTIONS AND CORRECT
ANSWERS | ALREADY GRADED A+ |
VERIFIED ANSWERS | LATEST
VERSION (JUST RELEASED)
According to the UHDDS, in order to assign a code for
another diagnosis, documentation must be present that:
a. The condition is recorded in the patient record by a dietary
clerk
b. The condition is present in the admission department data
c. The condition was clinically evaluated or therapeutically
treated, extended the length of hospital stay, or increased
nursing care or monitoring
d. The condition is considered to be essential by the family
Correct Answer: C
For reporting purposes the definition for other
diagnoses is interpreted as additional conditions that
affect patient care in terms of requiring: clinical evaluation;
or therapeutic treatment; or diagnostic procedures; or
extended length of hospital stay; or increased
nursing care or monitoring (CMS 2018a, Section III, 105-106).
,Most hospitals require a medical record is completed
within:
a. 5 days
b. 10 days
c. 7 days
d. 30 days
Correct Answer: D
The Medicare Conditions of Participation and the Joint
Commission require that the medical record is completed
no later than 30 days following discharge of the patient
(Brickner 2016, 84).
Infusion of Herceptin, a monoclonal antibody used for
treatment of breast cancer in patients carrying a certain
mutation of the HER2 gene, is classified as:
a. Chemotherapy
b. Radiotherapy
c. Molecular Targets
d. Immunotherapy
Correct Answer: C
Targeted cancer therapies are drugs or other substances
that block the growth and spread of cancer by interfering
with specific molecules involved in tumor growth and
,progression.
Herceptin is a type of targeted cancer therapy also referred
to as a monoclonal antibody (National Cancer Institute
2018).
A patient has findings suggestive of chronic obstructive
pulmonary disease (COPD) on chest x-ray. The attending
physician mentions the x-ray finding in one progress note
but no medication, treatment, or further evaluation is
provided. The coder should:
a. Query the attending physician regarding the x-ray finding
b. Code the condition because the documentation reflects it
c. Question the radiologist regarding whether to code this
condition
d. Use a code from abnormal findings to reflect the condition
Correct Answer: A
Query the attending physician regarding the clinical
significance of the findings and request that appropriate
documentation be provided. This is an example of a
circumstance where the chronic condition must be
verified. All secondary conditions must meet the
UHDDS definitions; it is not clear if COPD does (CMS 2018a,
Section III, 105-106).
, If a patient undergoes an inpatient procedure and the final
summary diagnosis is different from the diagnosis on the
pathology report, the coder should:
a. Code only from the discharge diagnoses
b. Code the diagnosis reflected on the pathology report
c. Code the most severe symptom
d. Query the attending physician as to the final diagnosis
Correct Answer: D
Coding strictly from the pathology report is not
appropriate as the coder is assigning a diagnosis without
the attending physician's corroboration. It is therefore
appropriate to query the physician (CMS 2018a, Section
III, 105-106).
A 56-year-old woman is admitted to an acute-care facility
from a skilled nursing facility. The patient has multiple
sclerosis and hypertension. During the course of
hospitalization, a decubitus ulcer is found and debrided at
the bedside by a physician. There is no typed
operative report and no pathology report. The coder should:
a. Use an excisional debridement code as these charts are
rarely reviewed to verify the excisional debridement
b. Code with a nonexcisional debridement procedure code
c. Query the healthcare provider who performed the
procedure to determine if the debridement was
excisional
d. Eliminate the procedure code all together
