CCS-CERTIFIED CODING SPECIALIST EXAM 2
| (WITH RATIONALES) QUESTIONS AND
VERIFIED ANSWERS GRADED A+ 2026
UPDATE!!
A patient was admitted with hyperglycemia, uncontrolled
thirst, constant hunger, and weight gain. Testing indicates that
the patient has Type 2 diabetes which is noted in the discharge
summary. What is the POA indicator for the diabetes?
a. Y
b. N
c. U
d. W ANSWER Correct Answer: A
Chronic conditions should have a POA indicator of Y, even if
they are diagnosed after admission (CMS 2020a, 117-121)
A condition that is established after study to be chiefly
responsible for the admission is the: a. Reason for visit
b. Principal procedure
c. A complication of outpatient care
d. Principal diagnosis ANSWER Correct
,Answer: D
The principal diagnosis is defined as the condition "established
after study to be chiefly responsible for occasioning the
admission of the patient to the hospital for care." Selecting the
principal diagnosis depends on the circumstances of the
admission and why the patient was admitted (Schraffenberger
and Palkie 2020, 92; CMS 2020a, Section II, 107).
A patient is admitted to the hospital with a high fever, chills,
tachycardia, and a respiration rate of 26. Lactic acidosis is noted
in the labs. Pneumonia is diagnosed and the patient admitted
to ICU where antibiotics are given along with Levophed to help
maintain the patient's blood pressure which was in the
extremely low range. The patient's breathing was erratic and
mechanical ventilation was initiated. With a final diagnosis of
pneumonia, what is the query opportunity for this record? a. Is
this aspiration pneumonia?
b. Is this septic shock?
c. Is this Staphylococcus aureus pneumonia?
d. Is this sepsis? ANSWER Correct Answer: B The clinical
indicators of fever, chills, tachycardia, tachypnea, and lactic
acidosis all point to sepsis, but with the addition of
respiratory issues requiring mechanical ventilation, and
circulatory failure requiring the use of vasopressors, this
, condition more likely represents septic shock and should be
queried (Schraffenberger and Palkie 2020, 122-123).
Two areas of documentation in the health record that are
significant areas of focus of accrediting agencies are:
a. Incident reports notation in the medical record and
attorney's notes
b. Past medical reports and social worker's notes
c. Timeliness and legibility of medical documents
d. Patient documentation and pastoral counseling - ✔✔✔
Correct Answer > Correct Answer: C
There are many areas that accrediting agencies review but
timeliness and legibility of medical documents are two of the
most important aspects of health record management (Johns
2020, 85; CMS 2011, 2).
Which of the following is not a function of the outpatient code
editor (OCE)?
a. Editing the data on the claim for accuracy
b. Specifying the action the FI should take when specific edits
occur
, c. Assigning APCs to the claim (for hospital outpatient services)
d. Determining payment-related conditions that require direct
reference to ICD-10-CM codes ANSWER Correct Answer: D
The outpatient code editor (OCE) performs four basic functions:
editing the data on the claim for accuracy, specifying the action
the fiscal intermediary should take when specific edits occur,
assigning APCs to the claim (for hospital outpatient services),
and determining payment-related conditions that require direct
reference to HCPCS codes or modifiers (Smith 2020, 314-315).
A patient comes into the hospital with chest pain, shortness of
breath, and a history of COPD. An MRI, chest x-ray, troponin,
and CKMB are ordered. A coder might expect a medical
necessity edit to be triggered for which test? a. Troponin
b. Chest x-ray
c. MRI
d. CKMB ANSWER Correct Answer: C
The chest x-ray, CKMB, and troponin are all related to the
diagnoses given, but there is no diagnosis that supports medical
necessity for the MRI (Casto 2018, 256).
| (WITH RATIONALES) QUESTIONS AND
VERIFIED ANSWERS GRADED A+ 2026
UPDATE!!
A patient was admitted with hyperglycemia, uncontrolled
thirst, constant hunger, and weight gain. Testing indicates that
the patient has Type 2 diabetes which is noted in the discharge
summary. What is the POA indicator for the diabetes?
a. Y
b. N
c. U
d. W ANSWER Correct Answer: A
Chronic conditions should have a POA indicator of Y, even if
they are diagnosed after admission (CMS 2020a, 117-121)
A condition that is established after study to be chiefly
responsible for the admission is the: a. Reason for visit
b. Principal procedure
c. A complication of outpatient care
d. Principal diagnosis ANSWER Correct
,Answer: D
The principal diagnosis is defined as the condition "established
after study to be chiefly responsible for occasioning the
admission of the patient to the hospital for care." Selecting the
principal diagnosis depends on the circumstances of the
admission and why the patient was admitted (Schraffenberger
and Palkie 2020, 92; CMS 2020a, Section II, 107).
A patient is admitted to the hospital with a high fever, chills,
tachycardia, and a respiration rate of 26. Lactic acidosis is noted
in the labs. Pneumonia is diagnosed and the patient admitted
to ICU where antibiotics are given along with Levophed to help
maintain the patient's blood pressure which was in the
extremely low range. The patient's breathing was erratic and
mechanical ventilation was initiated. With a final diagnosis of
pneumonia, what is the query opportunity for this record? a. Is
this aspiration pneumonia?
b. Is this septic shock?
c. Is this Staphylococcus aureus pneumonia?
d. Is this sepsis? ANSWER Correct Answer: B The clinical
indicators of fever, chills, tachycardia, tachypnea, and lactic
acidosis all point to sepsis, but with the addition of
respiratory issues requiring mechanical ventilation, and
circulatory failure requiring the use of vasopressors, this
, condition more likely represents septic shock and should be
queried (Schraffenberger and Palkie 2020, 122-123).
Two areas of documentation in the health record that are
significant areas of focus of accrediting agencies are:
a. Incident reports notation in the medical record and
attorney's notes
b. Past medical reports and social worker's notes
c. Timeliness and legibility of medical documents
d. Patient documentation and pastoral counseling - ✔✔✔
Correct Answer > Correct Answer: C
There are many areas that accrediting agencies review but
timeliness and legibility of medical documents are two of the
most important aspects of health record management (Johns
2020, 85; CMS 2011, 2).
Which of the following is not a function of the outpatient code
editor (OCE)?
a. Editing the data on the claim for accuracy
b. Specifying the action the FI should take when specific edits
occur
, c. Assigning APCs to the claim (for hospital outpatient services)
d. Determining payment-related conditions that require direct
reference to ICD-10-CM codes ANSWER Correct Answer: D
The outpatient code editor (OCE) performs four basic functions:
editing the data on the claim for accuracy, specifying the action
the fiscal intermediary should take when specific edits occur,
assigning APCs to the claim (for hospital outpatient services),
and determining payment-related conditions that require direct
reference to HCPCS codes or modifiers (Smith 2020, 314-315).
A patient comes into the hospital with chest pain, shortness of
breath, and a history of COPD. An MRI, chest x-ray, troponin,
and CKMB are ordered. A coder might expect a medical
necessity edit to be triggered for which test? a. Troponin
b. Chest x-ray
c. MRI
d. CKMB ANSWER Correct Answer: C
The chest x-ray, CKMB, and troponin are all related to the
diagnoses given, but there is no diagnosis that supports medical
necessity for the MRI (Casto 2018, 256).
