CCS-P Exam Guide with Questions and
Answers/100% Correct/ Grade A+
For continuity of care, ambulatory care providers are more likely than providers of ACS to
rely on the documentation found in the - Answer Problem list
(PCPs, pharmacy consultations and transfer summaries are likely to be found on the records
of long-term care patients).
All of the following organizations make up the Cooperating Parties for the approval of ICD-
9-CM coding guidelines EXCEPT: - Answer Americal Medical Association
Define Status asthmaticus - Answer An acute asthmatic attack in which the degree of
bronchial obstruction is not relieved by usual treatments such as pinephrine or aminophylline.
Only a physician can diagnose status asthmaticus. If te coder suspects the condition based on
the symptoms in the record, the coder should query the physician.
A data element you would expect to be collected in the MDS but NOT in the UHDDS would
be: - Answer Level of cognition
Heart system transplant - Answer Is coded with Category III code because no Category I
code is available.
,The physician has ordered potassium replacement for the patient for a diagnosis of: - Answer
Hypokalemia
(decreased levels of potassium in the blood)
When the CPT index and tabular do not contain a code that descrbies an adequately
documented procedure that was performed by the physician, what action should the coder
take? - Answer Assign the nlisted cde from the orresponding anatomical section
One essential item to be captured on the physical exam is the: - Answer Objective survey of
body systems
(Performed during the PE. This adds objective data to the subjective data provided by the
patient. The exam includes all body systems).
Which of the following indices might be protected from unauthorized access through the use
of unique identifier codes assigned to members of the medical staff? - Answer Physician
index
Accreditation by Joint Commission is a voluntary activity for a facility and it is - Answer
required for reimbursement of certain patient groups
,Joint commission standards require that a complete history and physical be documented on
the health records of operative patients. Does this report carry a time requirement? - Answer
Yes, prior to surgery
What would be used to quickly gather the health records of all juvenile patients treated for
diabetes within the past 6 months? - Answer Disease index
(contains abstracting patient code numbers into a computer database, allowing a variety of
reports to be generated)
The lack of a discharge order may indcate that the patient left against medical advice. If this
situation occurs, you would expect to see the circumstances of the leave: - Answer
Documented in both the progress notes and the discharge summary.
When is an Incident report written? - Answer When there is an account of an unusual event
that has an adverse effect on a patient, employee, or facility visitor and it should never be
filed with the patient's record.
The foundation for communicating all patient care goals in long-term care settings is the -
Answer Interdisciplinary patient care plan
COP requires a consultation report when - Answer 1. Patients that are not a good surgical
risk.
, 2. Those with obscure diagnoses.
3. If a physician has doubts as to the best therapeutic measure to be taken.
4. If there is a question of criminal activity.
One distinct advantage of the EHR over paper-based health records is the - Answer
accessibility of the record by multiple data users.
Problem list - Answer Is a distinct compenent of the problem-oriented record that serves to
help index documentation throughout the record.
A POMR contains what? - Answer 1. H&P
2. Problem list (titles, #'s, dates)
3. Initial plan (diagnostic, therapeutic, pt ed plans)
4. Progress notes
All of which is summarized in a discharge summary or transfer note at the end of the stay.
R-ADT system contains - Answer Info re patients who are transferred to the oncology unit
(or other specialty unit).
R-ADT - Answer Registration-admission, discharge, and transfer system
Answers/100% Correct/ Grade A+
For continuity of care, ambulatory care providers are more likely than providers of ACS to
rely on the documentation found in the - Answer Problem list
(PCPs, pharmacy consultations and transfer summaries are likely to be found on the records
of long-term care patients).
All of the following organizations make up the Cooperating Parties for the approval of ICD-
9-CM coding guidelines EXCEPT: - Answer Americal Medical Association
Define Status asthmaticus - Answer An acute asthmatic attack in which the degree of
bronchial obstruction is not relieved by usual treatments such as pinephrine or aminophylline.
Only a physician can diagnose status asthmaticus. If te coder suspects the condition based on
the symptoms in the record, the coder should query the physician.
A data element you would expect to be collected in the MDS but NOT in the UHDDS would
be: - Answer Level of cognition
Heart system transplant - Answer Is coded with Category III code because no Category I
code is available.
,The physician has ordered potassium replacement for the patient for a diagnosis of: - Answer
Hypokalemia
(decreased levels of potassium in the blood)
When the CPT index and tabular do not contain a code that descrbies an adequately
documented procedure that was performed by the physician, what action should the coder
take? - Answer Assign the nlisted cde from the orresponding anatomical section
One essential item to be captured on the physical exam is the: - Answer Objective survey of
body systems
(Performed during the PE. This adds objective data to the subjective data provided by the
patient. The exam includes all body systems).
Which of the following indices might be protected from unauthorized access through the use
of unique identifier codes assigned to members of the medical staff? - Answer Physician
index
Accreditation by Joint Commission is a voluntary activity for a facility and it is - Answer
required for reimbursement of certain patient groups
,Joint commission standards require that a complete history and physical be documented on
the health records of operative patients. Does this report carry a time requirement? - Answer
Yes, prior to surgery
What would be used to quickly gather the health records of all juvenile patients treated for
diabetes within the past 6 months? - Answer Disease index
(contains abstracting patient code numbers into a computer database, allowing a variety of
reports to be generated)
The lack of a discharge order may indcate that the patient left against medical advice. If this
situation occurs, you would expect to see the circumstances of the leave: - Answer
Documented in both the progress notes and the discharge summary.
When is an Incident report written? - Answer When there is an account of an unusual event
that has an adverse effect on a patient, employee, or facility visitor and it should never be
filed with the patient's record.
The foundation for communicating all patient care goals in long-term care settings is the -
Answer Interdisciplinary patient care plan
COP requires a consultation report when - Answer 1. Patients that are not a good surgical
risk.
, 2. Those with obscure diagnoses.
3. If a physician has doubts as to the best therapeutic measure to be taken.
4. If there is a question of criminal activity.
One distinct advantage of the EHR over paper-based health records is the - Answer
accessibility of the record by multiple data users.
Problem list - Answer Is a distinct compenent of the problem-oriented record that serves to
help index documentation throughout the record.
A POMR contains what? - Answer 1. H&P
2. Problem list (titles, #'s, dates)
3. Initial plan (diagnostic, therapeutic, pt ed plans)
4. Progress notes
All of which is summarized in a discharge summary or transfer note at the end of the stay.
R-ADT system contains - Answer Info re patients who are transferred to the oncology unit
(or other specialty unit).
R-ADT - Answer Registration-admission, discharge, and transfer system
