CCS PRACTICE EXAM 1 Questions and Verified
Approved Answers Graded 100% A +
1. 45-year-old patient admitted with Insulin dependent diabetes. The type of diabetes is not
specified in the medical record. How should this be coded?
a. E11.9, Z79.4
b. E11.8
c. E11.8, Z79.4
d. Z79.4, E11.8 - CORRECT ANSWER ✔✔ -a. E11.9, Z79.4
If the type of diabetes mellitus is not documented in the medical record the default is E11.-, Type
2 diabetes mellitus. Code Z79.4, Long term (current) use of insulin, should also be assigned for
patients who take insulin (CMS 2018a, Section I.C.4.a.2, 34).
A 65-year-old male patient is being assessed for possible colon cancer and treated in the special
procedure unit of the hospital. He undergoes a colonoscopy into the ascending colon with biopsy
of a suspicious area in the transverse colon using the cold biopsy forceps. In addition, a colonic
ultrasound of the area is performed, with transmural biopsy of an area of the mesentery adjacent
to the transverse colon. Assign the appropriate CPT codes.
a. 45384, 45342
b. 45380, 45391
c. 45384, 45392
,d. 45380, 45392 - CORRECT ANSWER ✔✔ -d. 45380, 45392
Use index entry Colonoscopy, flexible, biopsy to assign CPT 45380 and entry Colonoscopy,
flexible, ultrasound for 45392. The CPT coding guidelines and descriptions of colonoscopy
codes and the Colonoscopy Decision Tree should be referenced for correct coding of these
procedures (AMA CPT Professional Edition 2018, 314-317).
A 65-year-old man is admitted due to an acute myocardial infarction. The patient also has
coronary artery disease. How should this be coded?
a. CAD, AMI
b. AMI
c. AMI, CAD
d. Query the physician for the principal diagnosis - CORRECT ANSWER ✔✔ -c. AMI, CAD
If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI),
the AMI should be sequenced before the coronary artery disease (CMS 2018a, Section I.C.9.b,
44).
A 70-year-old patient was admitted with pneumonia. The history and physical documented that
the patient has a history of diabetes, hypertension, and migraine headache about 10 years ago
,without recurrence. The patient was administered IV antibiotics, metformin, and Altace during
the hospitalization. Which conditions would be reported at the time of discharge?
a. Pneumonia, diabetes, hypertension, and migraine headaches
b. Pneumonia, diabetes, hypertension, and history of migraine headaches
c. Pneumonia, diabetes, and hypertension
d. Pneumonia - CORRECT ANSWER ✔✔ -c. Pneumonia, diabetes, and hypertension
Pneumonia, diabetes, hypertension should be coded. The migraine headaches are a past condition
and would not be coded as per the reporting guidelines for the UHDDS for "other conditions"
(CMS 2018a, Section III, 105-106).
A 75-year-old female was admitted for acute myocardial infarction and underwent a diagnostic
cardiac catheterization. Following the catheterization, the patient developed a thrombophlebitis
documented as due to the catheter in the common femoral artery. The thrombophlebitis would be
coded as:
a. T81.718A, Complication of other artery following a procedure, not elsewhere classified, initial
encounter
b. I97.51, Accidental puncture and laceration of a circulatory system organ or structure during a
circulatory system procedure
, c. I72.4, Aneurysm of artery of lower extremity
d. I97.52, Accidental puncture and laceration of a circulatory system organ or structure during
other procedure - CORRECT ANSWER ✔✔ -a. T81.718A, Complication of other artery
following a procedure, not elsewhere classified, initial encounter
Thrombophlebitis occurred in the artery where the catheterization was performed and the cause
of the thrombophlebitis is documented as due to the catheterization. Thrombophlebitis resulting
from a procedure is listed as T81.72. When the tabular is reviewed, this code relates to a vein.
The exercise states that the artery is the location of the thrombophlebitis. Therefore a code from
the T81.718 category is used (CMS 2018a, Section I.B.16, 18).
A 75-year-old woman is admitted to the hospital after tripping and falling at home. She
underwent an open reduction with internal fixation of the femur. Which of the following would
be important to capture in addition to diagnostic codes?
a. External cause codes for Cause of Injury and Place of Occurrence
b. External cause codes for Cause of Injury, Place of Occurrence, Activity, and Status
c. External cause codes for Cause of Injury, Place of Occurrence, and Activity
d. External cause codes for Cause of Injury only - CORRECT ANSWER ✔✔ -b. External cause
codes for Cause of Injury, Place of Occurrence, Activity, and Status
