CCS Practice Exam 2 complete 2024
update A+ graded
A 23 year old female is admitted for vaginal bleeding following a miscarriage two weeks
prior to this admission. She afebrile at this time and is treated with an aspiration dilation
and curettage. Products of conception are found. Which of the following should be the
principle diagnosis?
a. O03.1, Delayed or excessive hemorrhage following incomplete spontaneous abortion
b. O08.1, Delayed or excessive hemorrhage following ectopic and molar pregnancy
c. R57.9, Shock, unspecified
d. T81.10XA, Postprocedural shock unspecified, initial encounter - answer a. O03.1,
Delayed or excessive hemorrhage following incomplete spontaneous abortion
A psychiatrist documents that a patient has wide mood swings from excessive
happiness to loss of energy and crying. What condition is suspected?
a. Bipolar disorder
b. Major depression
c. Anxiety
d. Psychosis - answer A. Bipolar disorder
A patient with a cephalic presentation anticipating a vaginal delivery failed to progress.
After measurement of the fetal head and a trial of oxytocin, the patient underwent a
cesarean section. What condition should the coder suspect and query the physician
about?
a. Twin pregnancy
b. Early delivery
c. Eclampsia
d. Cephalopelvic disproportion - answer d. Cephalopelvic disproportion
A 45 year old woman underwent a carotid bypass and experienced a significant drop in
blood pressure during the surgery. The documentation suggested the patient may have
,had a myocardial infarction. In accordance with coding guidelines, what should the
coder do?
a. Code complication of surgery NOS.
b. Query the physician to determine if the patient had hypotension.
c. Query the physician to determine if there was a complication of surgery.
d. Code preoperative shock. - answer c. Query the physician to determine if there
was a complication of surgery.
If a patient's discharge summary does not contain a diagnosis that is documented by
the anesthesiologist in a preoperative evaluation and that would impact MS-DRG
assignment, the coder should:
a. Code only from the discharge diagnosis
b. Code the diagnosis reflected on the anesthesia preoperative evaluation
c. Code the most severe symptom
d. Query the attending physician regarding the clinical significance of that diagnosis -
answer d. Query the attending physician regarding the clinical significance of that
diagnosis
A patient has documentation of esophageal varices. What condition may be related that
may affect the coding?
a. Arthritis
b. Liver disease
c. Chronic obstructive pulmonary disease
d. Erythema - answer b. Liver disease
A patient admitted with acute abdominal pain, is fount to have appendicitis, and has an
appendectomy. The patient has a length of stay for 2 days. What type of patient
encounter is this?
a. Impatient
b. Outpatient
c. Long term care
d. Rehabilitation - answer a. Inpatient
A patient was treated in the emergency department for a swollen knee and an aspiration
of the joint was performed. The patient was then discharged home. It is important to
make sure that which of the following are documented and captured for billing
purposes?
a. X-ray and other types of radiology examination
b. Procedures performed including the aspiration of the joint
c. Examination and management in the emergency department
d. All services provided including diagnostic and treatment procedures, as well as
physician services - answer d. All services provided including diagnostic and
treatment procedures, as well as physician services.
A patient has documentation on the discharge summary of urosepsis. The coding staff
queries the attending physician about the condition and is provided further information
that the patient has septicemia. This is in alignment with the laboratory test and
, medication given but the diagnosis of septicemia was not documented by the physician.
How should the physician be requested to document the septicemia?
a. A brand new history and physical should be dictated to replace the one in the record.
b. An addendum to the chart should be written.
c. The new information should be squeezed in between lines within the progress notes
of the last day.
d. The query sheet will be sufficient to document this information. - answer b. An
addendum to the chart should be written.
The committee responsible for medical record completion reports to which medical staff
committee?
a. Chief executive officer of the facility
b. Medical Executive Committee
c. Discharge Planning Committee
d. Chief nursing officer - answer b. Medical Executive Committee
Two areas of documentation in the medial record that are significant areas of focus of
accrediting agencies are:
a. Incident reports notion in the medical record and attorney's notes
b. Past medical reports and social worker notes
c. Timeliness and legibility of medical documents
d. Patient documentation and pastoral counseling - answer c. Timeliness and
legibility of medical documents
In teaching facilities where electronic signatures are used for residents and attending
physicians:
a. Attending signature is all that is needed
b. Resident signature is all that is needed
c. Resident should co-sign after that attending signs the document
d. Attending should co-sign after the resident signs the document - answer d.
Attending should co-sign after the resident signs the document
An 84 year old woman was admitted and discharged with hemiplegia and aphasia. A CT
scan of the brain was performed that revealed an acute cerebral infarction and possible
small brain mass. After further testing, the patient was discharged with a final diagnosis
of acute cerebral infarction. The condition(s) that should be coded are:
a. Acute cerebral infarction
b. Hemiplegia and aphasia
c. Acute cerebral infarction, hemiplegia and aphasia
d. Possible brain mass, hemiplegia and aphasia - answer c. Acute cerebral infarction,
hemiplegia and aphasia
An inpatient is discharged with a diagnosis of "either irritable bowel or pancreatitis".
Which condition would be the principal diagnosis?
a. Code both and sequence according to the circumstances of the admission
b. Pancreatitis
c. Irritable bowel syndrome
update A+ graded
A 23 year old female is admitted for vaginal bleeding following a miscarriage two weeks
prior to this admission. She afebrile at this time and is treated with an aspiration dilation
and curettage. Products of conception are found. Which of the following should be the
principle diagnosis?
a. O03.1, Delayed or excessive hemorrhage following incomplete spontaneous abortion
b. O08.1, Delayed or excessive hemorrhage following ectopic and molar pregnancy
c. R57.9, Shock, unspecified
d. T81.10XA, Postprocedural shock unspecified, initial encounter - answer a. O03.1,
Delayed or excessive hemorrhage following incomplete spontaneous abortion
A psychiatrist documents that a patient has wide mood swings from excessive
happiness to loss of energy and crying. What condition is suspected?
a. Bipolar disorder
b. Major depression
c. Anxiety
d. Psychosis - answer A. Bipolar disorder
A patient with a cephalic presentation anticipating a vaginal delivery failed to progress.
After measurement of the fetal head and a trial of oxytocin, the patient underwent a
cesarean section. What condition should the coder suspect and query the physician
about?
a. Twin pregnancy
b. Early delivery
c. Eclampsia
d. Cephalopelvic disproportion - answer d. Cephalopelvic disproportion
A 45 year old woman underwent a carotid bypass and experienced a significant drop in
blood pressure during the surgery. The documentation suggested the patient may have
,had a myocardial infarction. In accordance with coding guidelines, what should the
coder do?
a. Code complication of surgery NOS.
b. Query the physician to determine if the patient had hypotension.
c. Query the physician to determine if there was a complication of surgery.
d. Code preoperative shock. - answer c. Query the physician to determine if there
was a complication of surgery.
If a patient's discharge summary does not contain a diagnosis that is documented by
the anesthesiologist in a preoperative evaluation and that would impact MS-DRG
assignment, the coder should:
a. Code only from the discharge diagnosis
b. Code the diagnosis reflected on the anesthesia preoperative evaluation
c. Code the most severe symptom
d. Query the attending physician regarding the clinical significance of that diagnosis -
answer d. Query the attending physician regarding the clinical significance of that
diagnosis
A patient has documentation of esophageal varices. What condition may be related that
may affect the coding?
a. Arthritis
b. Liver disease
c. Chronic obstructive pulmonary disease
d. Erythema - answer b. Liver disease
A patient admitted with acute abdominal pain, is fount to have appendicitis, and has an
appendectomy. The patient has a length of stay for 2 days. What type of patient
encounter is this?
a. Impatient
b. Outpatient
c. Long term care
d. Rehabilitation - answer a. Inpatient
A patient was treated in the emergency department for a swollen knee and an aspiration
of the joint was performed. The patient was then discharged home. It is important to
make sure that which of the following are documented and captured for billing
purposes?
a. X-ray and other types of radiology examination
b. Procedures performed including the aspiration of the joint
c. Examination and management in the emergency department
d. All services provided including diagnostic and treatment procedures, as well as
physician services - answer d. All services provided including diagnostic and
treatment procedures, as well as physician services.
A patient has documentation on the discharge summary of urosepsis. The coding staff
queries the attending physician about the condition and is provided further information
that the patient has septicemia. This is in alignment with the laboratory test and
, medication given but the diagnosis of septicemia was not documented by the physician.
How should the physician be requested to document the septicemia?
a. A brand new history and physical should be dictated to replace the one in the record.
b. An addendum to the chart should be written.
c. The new information should be squeezed in between lines within the progress notes
of the last day.
d. The query sheet will be sufficient to document this information. - answer b. An
addendum to the chart should be written.
The committee responsible for medical record completion reports to which medical staff
committee?
a. Chief executive officer of the facility
b. Medical Executive Committee
c. Discharge Planning Committee
d. Chief nursing officer - answer b. Medical Executive Committee
Two areas of documentation in the medial record that are significant areas of focus of
accrediting agencies are:
a. Incident reports notion in the medical record and attorney's notes
b. Past medical reports and social worker notes
c. Timeliness and legibility of medical documents
d. Patient documentation and pastoral counseling - answer c. Timeliness and
legibility of medical documents
In teaching facilities where electronic signatures are used for residents and attending
physicians:
a. Attending signature is all that is needed
b. Resident signature is all that is needed
c. Resident should co-sign after that attending signs the document
d. Attending should co-sign after the resident signs the document - answer d.
Attending should co-sign after the resident signs the document
An 84 year old woman was admitted and discharged with hemiplegia and aphasia. A CT
scan of the brain was performed that revealed an acute cerebral infarction and possible
small brain mass. After further testing, the patient was discharged with a final diagnosis
of acute cerebral infarction. The condition(s) that should be coded are:
a. Acute cerebral infarction
b. Hemiplegia and aphasia
c. Acute cerebral infarction, hemiplegia and aphasia
d. Possible brain mass, hemiplegia and aphasia - answer c. Acute cerebral infarction,
hemiplegia and aphasia
An inpatient is discharged with a diagnosis of "either irritable bowel or pancreatitis".
Which condition would be the principal diagnosis?
a. Code both and sequence according to the circumstances of the admission
b. Pancreatitis
c. Irritable bowel syndrome
