CCS exam prep/28 Accurate Questions
and Answers 2024-2025
- date and location inconsistencies
-missing physician signatures
-incorrect patient identification - -Common documentation errors
-"Separate procedure" according to CPT (current procedural terminology) - -
When performed in conjunction with another service, is considered an
integral part of the major service
-7 - -number of elements the OIG outlines for a compliance program
-A) Control of cost
B) Maintaining Confidentiality
C) Accessibility
D) Maintaining security of the healthcare record - -Implementation of the
electronic health record offers many challenges. Which would NOT be
considered a critical challenge
(c)
-acute and chronic conditions - -if separate subterms for acute and chronic
are listed at the same indention level, both codes are assigned with the code
for acute sequenced first
-American College of surgeons - -
-Code unconfirmed diagnosis as if established - -excludes: outpatient
services, HIV infection/illness and influenza due to certain identified influenza
viruses, or physician services (regardless of setting)
-Coding sepsis or severe sepsis - -coding of severe sepsis requires a
minimum of 2 codes:
-sequence 1st a code for underlying infection, followed by a code from
subcategory R65.2, severe sepsis
-If the casual organism is not documented, assign code A41.9, sepsis
unspecified
-concurrent review - -review of the medical record carried out while the
patient is actively receiving care
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