CCS Practice Exam 2 - Questions With Complete
Solutions
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 Correct
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 Correct 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 Correct 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. Correct 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 Correct 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 Correct 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 Correct 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 Correct 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.
Correct 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 Correct 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 Correct 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
Solutions
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 Correct
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 Correct 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 Correct 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. Correct 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 Correct 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 Correct 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 Correct 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 Correct 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.
Correct 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 Correct 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 Correct 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
