CCS RELIABLE EXAM EVALUATION QUESTIONS WITH
ANSWERS 2025/2026 GRADED A+
pseudomonas - A patient is admitted with pneumonia. Cultures are requested to
determine the infecting organism. Which of the following, if present, would alert the
coder to ask the physician whether or not this should be coded as Gram-negative
pneumonia?
pseudomonas
clostridium
staphylococcus
listeria
contact the HIM Director to refer to the Medical Director. - If a query is submitted to the
provider, and the coder receives no response within 5 days to a week, the coder should:
code whatever you can and move on.
phone the physician every day until a response is provided.
contact the HIM Director to refer to the Medical Director.
tell the CEO of the hospital
compliant. It can be answered from multiple choice. - A 43-year-old female went to the
clinic complaining of fever, dyspnea, and is sent for a chest x-ray to rule out pneumonia.
After examination, the physician documents pneumonia, confirmed. The query sent to
the attending physician read, "What type of pneumonia does this patient have: bacterial,
viral, fungal, or other?" This query is:
not valid. There is no such diagnosis as pneumonia.
not compliant because it is too direct.
compliant. It can be answered from multiple choice.
not compliant. Queries must be written as Yes or No.
CDIP (Clinical Documentation Improvement Practitioner) - Improving the specificity of
clinical reports through the use of a physician query is a documentation goal that may
be shared by the coding staff and this specialist:
, query - A powerful communication tool used to clarify documentation in a health record
and achieve accurate code assignment is called a
halo effect
POA
query
SOR
POA (Present on Admission) - is defined as being present at the time the order for
inpatient admission occurs.
either open-ended or multiple choice. - The question or questions in a query must be
written to be:
What is the cause of the patient's edema? - The query asked, "Do you agree that the
edema in the patient's legs were caused by his previous diagnosis of malnutrition?" A
legal version of this question would be:
Please add to the documentation the connection between the edema and the patient's
nutrition.
What is the cause of the patient's edema?
Lower extremity bilateral edema is usually caused by malnutrition. Do you agree?
Did the malnutrition cause the patient's edema?
contradictory - The Review of Systems states, "No inflammation of the bronchioles".
The patient was treated with a Croup Tent. The Assessment/Diagnosis line of this chart
states, "Bronchiolitis". This is a problem due to ______ documentation.
contradictory
ambiguity
missing information
inaccuracy
Yes, there needs to be a treatment plan. - A 33-year-old male went to his primary care
physician (PCP) with heartburn-like symptoms including reflux, disturbed sleep, and
elevated blood pressure. Upon questioning, the PCP asked about alcohol consumption.
At first, he denied any, then admitted to drinking half to 1 bottle of scotch per night
ANSWERS 2025/2026 GRADED A+
pseudomonas - A patient is admitted with pneumonia. Cultures are requested to
determine the infecting organism. Which of the following, if present, would alert the
coder to ask the physician whether or not this should be coded as Gram-negative
pneumonia?
pseudomonas
clostridium
staphylococcus
listeria
contact the HIM Director to refer to the Medical Director. - If a query is submitted to the
provider, and the coder receives no response within 5 days to a week, the coder should:
code whatever you can and move on.
phone the physician every day until a response is provided.
contact the HIM Director to refer to the Medical Director.
tell the CEO of the hospital
compliant. It can be answered from multiple choice. - A 43-year-old female went to the
clinic complaining of fever, dyspnea, and is sent for a chest x-ray to rule out pneumonia.
After examination, the physician documents pneumonia, confirmed. The query sent to
the attending physician read, "What type of pneumonia does this patient have: bacterial,
viral, fungal, or other?" This query is:
not valid. There is no such diagnosis as pneumonia.
not compliant because it is too direct.
compliant. It can be answered from multiple choice.
not compliant. Queries must be written as Yes or No.
CDIP (Clinical Documentation Improvement Practitioner) - Improving the specificity of
clinical reports through the use of a physician query is a documentation goal that may
be shared by the coding staff and this specialist:
, query - A powerful communication tool used to clarify documentation in a health record
and achieve accurate code assignment is called a
halo effect
POA
query
SOR
POA (Present on Admission) - is defined as being present at the time the order for
inpatient admission occurs.
either open-ended or multiple choice. - The question or questions in a query must be
written to be:
What is the cause of the patient's edema? - The query asked, "Do you agree that the
edema in the patient's legs were caused by his previous diagnosis of malnutrition?" A
legal version of this question would be:
Please add to the documentation the connection between the edema and the patient's
nutrition.
What is the cause of the patient's edema?
Lower extremity bilateral edema is usually caused by malnutrition. Do you agree?
Did the malnutrition cause the patient's edema?
contradictory - The Review of Systems states, "No inflammation of the bronchioles".
The patient was treated with a Croup Tent. The Assessment/Diagnosis line of this chart
states, "Bronchiolitis". This is a problem due to ______ documentation.
contradictory
ambiguity
missing information
inaccuracy
Yes, there needs to be a treatment plan. - A 33-year-old male went to his primary care
physician (PCP) with heartburn-like symptoms including reflux, disturbed sleep, and
elevated blood pressure. Upon questioning, the PCP asked about alcohol consumption.
At first, he denied any, then admitted to drinking half to 1 bottle of scotch per night
