Practice questions for CCS

An 84-year-old woman was admitted and discharged with hemiplegia and aphasia. A CT scan of the brain was performed that revealed an acute cerebral infarction and a possible small brain mass. After further testing, the patient was discharged with a final diagnosis of acute cerebral infarction. The condition(s) that should be coded are:

a. Acute cerebral infarction
b. Hemiplegia and aphasia
c. Acute cerebral infarction, hemiplegia, and aphasia
d. Possible brain mass, hemiplegia, and aphasia

c

A patient is discharged with a diagnosis of acute pulmonary edema due to congestive heart failure. What condition(s) should be coded?

a. Acute pulmonary edema
b. Congestive heart failure
c. Acute pulmonary edema and congestive heart failure
d. Unable to determine based on the information provided

b

The patient was admitted from the emergency department because of chest pain. Following blood work, it was determined that the patient had elevated CPKs and MB enzymes. The EKG shows nonspecific ST changes. What type of diagnosis might this indicate?

a. Unstable angina
b. Myocardial infarction
c. Congestive heart failure
d. Mitral valve stenosis

b

A patient is admitted and diagnosed with a fever and urinary burning. The discharge diagnosis is Eschericia coli, urosepsis. Which of the following represents the correct diagnosis and appropriate sequence of those conditions?

a. Fever, urinary burning, urosepsis
b. Fever, urinary burning, sepsis
c. Eschericia coli, urinary tract infection
d. Urinary tract infection, Eschericia coli

d

A patient was admitted with heart failure within one week of a heart transplant. Due to the timing, the coder thought that it may represent a postoperative transplant rejection following heart transplant. What action(s) should the coding staff take?

a. Query the physician
b. Assign the codes for the postoperative transplant rejection
c. Assign only the code for the transplant rejection
d. Assign only the code for heart failure

a

A patient is admitted to a psychiatric unit of an acute-care facility. The patient experienced the following symptoms almost every day for the last month: loss of interest or pleasure in most or all activities. which is a change from her prior level of functioning. She has also gained 15 lbs, has difficulty falling asleep, feels fatigued, and has difficulty making decisions. What potential diagnosis most closely fits the patient’s overall symptoms?

a. Insomnia
b. Major depression
c. Reye’s syndrome
d. Bipolar disorder

b

A patient is admitted to the hospital complaining of abdominal pain. Following evaluation, it was determined that the patient had an intestinal obstruction due to adhesions from a prior abdominal surgery. The patient underwent an exploratory laparotomy with lysis of adhesions. What conditions should be coded?

a. Abdominal pain, abdominal adhesions, abdominal obstruction, laparotomy, lysis of adhesions
b. Abdominal adhesions, abdominal obstruction, postoperative complications of the digestive system, laparotomy, lysis of adhesions
c. Abdominal adhesions with obstruction, lysis of adhesions
d. Abdominal adhesions and abdominal obstruction, postoperative complications of the digestive system, lysis of adhesions

c

A patient has a principal diagnosis of pneumonia (486) (MS-DRG 195). Which of the following may legitimately change the coding of the pneumonia in accordance with the UHDDS and relevant clinical documentation?

a. Sputum culture reflects growth of normal flora
b. Patient has a positive gram stain
c. Patient is found to have dysphagia with aspiration
d. Patient has nonproductive sputum

c

A patient is diagnosed with infertility due to endometriosis and undergoes a laparoscopic laser destruction of pelvic endometriosis. In order to code this encounter accurately, what steps must the coder take?

a. Review the operative report to determine what procedure codes to use and also to determine the site or sites of endometriosis so codes with the highest specificity may be assigned, and use infertility as a principal diagnosis
b. Review the operative report to determine where the laser was used in the pelvis to the site or sites of endometriosis can be specified, and assign a principal diagnosis of infertility
c. Review the operative report to determine where the laser was used in the pelvis so the site or sites of endometriosis can be specified as principal, and assign the secondary diagnosis of infertility
d. Review the operative report to determine what procedure codes to use and also to determine the site or sites of endometriosis so codes with the highest specificity may be assigned, and use the diagnosis of infertility as a secondary condition

d

In order to establish the adequacy of documentation the following must be reflected

a. Decisions of patient’s caregivers
b. Quantitative analysis of the number of pages
c. Ancillary forms and consents
d. Care rendered to the patient and the patient’s response

d

Authentication of health record entries means to

a. Create facsimiles of documents
b. Prove authorship of documents
c. Develop documents
d. Use a rubber stamp on random sets of documents

b

The requirements for documentation and record completion (documents such as history and physicals, discharge summaries, and consultations) as well as penalties for nonadherence must be specified in

a. Hospital rules and regulations
b. Conditions of nonparticipation
c. Medical staff bylaws
d. Nursing staff policies

c

A patient was given heparin during hospitalization for a deep vein thrombophlebitis of the right lower extremity. The patient had back pain and the nurse was not answering the bell, so he decided the take two aspirin. The interaction between the aspirin and heparin caused a subcutaneous hemorrhage of the thigh of the right lower extremity. How should the interaction between aspirin and heparin coded?

a. Poisoning codes for aspirin and heparin, and subcutaneous hemorrhage of the thigh of the right lower extremity as secondary conditions
b. Poisoning codes for aspirin and heparin, and subcutaneous hemorrhage of the thigh of the right lower extremity as principal
c. Adverse effects of drugs for aspirin and heparin, and subcutaneous hemorrhage of the thigh of the right lower extremity as secondary conditions
d. Adverse effects of drugs for aspirin and heparin as secondary diagnoses, and subcutaneous hemorrhage of the thigh of the right lower extremity as principal

a

A patient is admitted to the hospital for pain due to pacemaker electrode. The patient also has hypothyroidism due to partial thyroidectomy seven years ago and a breast cyst. The pacemaker electrode was relocated and synthroid was given during hospitalization. The diagnostic codes (excluding E codes) that should be assigned are

a. 996.01, 244.0
b. 996.61, 244.0, 610.0
c. 996.72, 244.0
d. 996.72, 244.0, 610.0

c

A patient was admitted to the emergency department for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease. List the diagnoses that would be coded in the order of sequence

a. Abdominal pain, infectious gastroenteritis, chronic obstructive pulmonary disease, angina
b. Infectious gastroenteritis, chronic obstructive pulmonary disease, angina
c. Gastroenteritis, abdominal pain, angina
d. Diarrhea, chronic obstructive pulmonary disease, angina

b

A patient was admitted to the endoscopy unit for a screening colonoscopy. During the colonoscopy, polyps of the colon were found and a polypectomy was performed. What diagnostic codes should be used and how should they be sequenced?

a. V76.51
b. 211.3
c. V76.51, 211.3
d. 211.3, V76.51

c

The nurse reviews with the client the risk factors associated with atherosclerosis. Nonmodifiable risk factors that the nurse instructs the client about include A. diabetes. B. age. C. dietary preferences. D. exercise level. b Which of the following controllable risk …

(113) If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? A) Length of the lesion as described …

A patient is in end-stage renal failure. What are the signs and symptoms that the nurse is likely to find while assessing neurologic function? Select all that apply. – Restless leg syndrome – Nocturnal leg cramps – Asterixis (hand-flapping tremor) …

1. A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? The patient was oriented and alert when admitted The patient’s speech …

A nurse is caring for a client who had a hypophysectomy. For which complication specific to this surgery should the nurse assess the client for early manifestations? A) urinary retention B) respiratory distress C) bleeding at the suture line D) …

Multiple organ dysfunction syndrome (MODS) can be caused by: a. septic shock. b. prolonged tissue hypoxia. c. uncontrolled systemic inflammation. d. all of the above. d. all of the above. A person is unresponsive to verbal stimuli, has a heart …

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