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CCS Exam Prep/72 Questions with Complete Solutions
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CCS Exam Prep/72 Questions withComplete Solutions
A 23-year old female is admitted for shock following treatment of an ectopic
pregnancy. This encounter would be coded as: - -O08.3, complication
following ectopic and molar pregnancies
-A 56-year old woman is admitted to an acute0care facility from a skilled
nursing facility. The patient has multiple sclerosis and hypertension. During
the course of hospitalization, a decubitus ulcer is found and debrided a the
bedside by a physician. There is no typed operative report and no pathology
report. The coder should: - -Query the healthcare provider who performed
the procedure to determine if the debridement was excisional
-A 64-year old female is admitted to the hospital with nausea, vomiting, and
edema. The patient has a history of diabetes and takes Metformin and
Lisinopril as prescribed. Blood sugar and blood pressure are monitored while
admitted. On the discharge summary, the final diagnoses of acute renal
failure and diabetes are documented. What is the query opportunity for this
record? - -Does the patient have hypertension?
-A 7 year old patient was admitted to the emergency department for
treatment of shortness of breath. The patient is given epinephrine and
nebulizer treatments. The shortness of breath and wheezing are unabeted
following treatment. What diagnosis should be suspected? - -Asthma with
status asthmaticus
-A completed and signed operative report needs clarification of the size of
the skin lesions that were removed. What process is used for that
clarification? - -Amendment
-A contract coder works for a hospital and, in the course of daily work,
routinely accesses protected patient health information. Under HIPAA, what
should be in place to permit access and protect patient privacy? - -Business
associate agreement
-A diabetic patient was admitted for a treatment of a pressure ulcer. The
patient also has a history of diabetic neuropathy and retinopathy. The
patient is blind and additional nursing care and extended time with the
patient was required. Which conditions should be coded at discharge? - -
Pressure ulcer, diabetic neuropathy and diabetic retinopathy, and blindness
, -A female patient is diagnosed with congestive heart failure. Which of the
following will increase the MS-DRG weight if present on admission? - -State
III pressure ulcer of coccyx
-A patient admitted with shoulder pain has an inpatient discharge with
principal diagnosis of either peptic ulcer or cholecystitis documented on the
history and physical. Both are equally treated and well documented. A coder
should: - -Code based on the circumstances of admission and if both are
equally treated, code either as principal
-A patient has findings suggestive of chronic obstructive pulmonary disease
(COPD) on chest x-ray. The attending physician mentions the x-ray findings
in one progress note. but no medications, treatments, or further evaluation is
provided. The coder should: - -Query the attending physician regarding the
x-ray finding
-A patient is admitted for seizures. What is the appropriate POA for the
external cause code of W06.XXA assigned because the patient fell out of bed
during a seizure in the ER? - -Y
-A patient is admitted with a high temperature, lethargy, hypotension,
tachycardia, oliguria, and elevated WBC. The patient also has more than
100,000 organisms of Escherichia coli per cc of urine. The attending
physician documents, "urosepsis.: What is the next step for the coder? - -Ask
the physician whether the patient had septic chock so that this may be used
as the principle diagnosis.
-A patient is admitted with an acute inferior myocardial infarction and
discharged alive. Which condition would increase the MS-DRG weight? - -
Respiratory failure
-According to the UHDDS, section III, the definition of other diagnoses is all
conditions that: - -Coexist at the time of admission, that develop
subsequently, or that affect the treatment received or the length of stay
-After a patient is discharged from the hospital, the medical record must be
reviewed for: - -Certain basic reports (for example, history and physical,
discharge summary, etc)
-After consulting with a physician, a coding supervisor has issued an internal
policy stating that all bedside debridement be coded as excisonal. Is this an
ethical practice for a coder to follow? - -No, internal policies cannot conflict
with requirements provided in coding guidelines
-Authentication of health record entries means to: - -Prove authorship of
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