EXAM 1, DOMAIN 1 - CLINICAL
DOCUMENTATION - CCS-P EXAM
QUESTIONS AND ANSWERS
The paper record format in which the entire record is arranged in strict chronological
order is called - Correct Answers -Integrated Health Record
In ICD-10-CM, which one of the following is NOT considered a complication of labor and
delivery? - Correct Answers -Cephalic or occipital presentation with spontaneous
vaginal delivery
A male patient is seen by the physician and diagnosed with pneumonia. The physician
too cultures to try to determine which organism was causing the pneumonia. Which of
the following organisms would alert the coder to code it as a gram-negative pneumonia?
- Correct Answers -Klebsiella
Which of the following data elements is needed to accurately assign a CPT preventative
medicine code? - Correct Answers -Age of the patient
The physician visits his patient in the hospital and indicates that the patient has
diabetes. Insulin is prescribed for and administered to the patient. What is the best
decision that the coding professional can make in this situation? - Correct Answers -
Assign a code for type 2 diabetes mellitus along with a code for the insulin use
Sometimes referred to as a "superbug" this organism is a major cause of hospital-
acquired infection - Correct Answers -Methicillin-resistant Staphylococcus aureus
(MRSA)
Which of the following is considered a prion disease, a family of rare progressive
neurodegenerative disorders? - Correct Answers -Creutzfeldt-Jakob disease
The coder notes that the physician has prescribed levothyroxine (Synthroid) for the
patient. The coder might find which of the following on the patients problem list? -
Correct Answers -Hypothyroidism
Documentation in the health record that relates to the patient's diagnoses and treatment
is considered what type of data? - Correct Answers -Clinical
DOCUMENTATION - CCS-P EXAM
QUESTIONS AND ANSWERS
The paper record format in which the entire record is arranged in strict chronological
order is called - Correct Answers -Integrated Health Record
In ICD-10-CM, which one of the following is NOT considered a complication of labor and
delivery? - Correct Answers -Cephalic or occipital presentation with spontaneous
vaginal delivery
A male patient is seen by the physician and diagnosed with pneumonia. The physician
too cultures to try to determine which organism was causing the pneumonia. Which of
the following organisms would alert the coder to code it as a gram-negative pneumonia?
- Correct Answers -Klebsiella
Which of the following data elements is needed to accurately assign a CPT preventative
medicine code? - Correct Answers -Age of the patient
The physician visits his patient in the hospital and indicates that the patient has
diabetes. Insulin is prescribed for and administered to the patient. What is the best
decision that the coding professional can make in this situation? - Correct Answers -
Assign a code for type 2 diabetes mellitus along with a code for the insulin use
Sometimes referred to as a "superbug" this organism is a major cause of hospital-
acquired infection - Correct Answers -Methicillin-resistant Staphylococcus aureus
(MRSA)
Which of the following is considered a prion disease, a family of rare progressive
neurodegenerative disorders? - Correct Answers -Creutzfeldt-Jakob disease
The coder notes that the physician has prescribed levothyroxine (Synthroid) for the
patient. The coder might find which of the following on the patients problem list? -
Correct Answers -Hypothyroidism
Documentation in the health record that relates to the patient's diagnoses and treatment
is considered what type of data? - Correct Answers -Clinical
