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CERTIFIED CODING SPECIALIST (CCS) FINAL EXAM
AND PRACTICE EXAMS 1& 2||2025-2026||ACTUAL
EXAMS WITH CORRECT DETAILED AND VERIFIED
ANSWERS WITH RATIONALES/A+ GRADE
FINAL EXAM PRACTICE 1& 2
- 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. b. E11. c. E11.8, Z79. d. Z79.4, E11.8 - ANSWERS- a. E11.9, Z79. RATIONALE : 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). The patient is diagnosed with a recurrent thyroglossal duct cyst. The surgeon locates the cyst using palpation, and an incision is created. The cyst is then excised. What is the correct CPT code assignment for this service? a. 60200 b. 60210 c. 60280 d. 60281 - ANSWERS- d. 60281 RATIONALE :CPT code 60281 is accessed using index entry Cyst, thyroglossal duct, excision resulting in code range 60280 - 60281. Code 60281 is correct for recurrent (AMA CPT Professional Edition 2018, 385). Most hospitals require a medical record is completed within: a. 5 days b. 10 days
c. 7 days d. 30 days - ANSWERS- d. 30 days RATIONALE : The Medicare Conditions of Participation and the Joint Commission require that the medical record is completed no later than 30 days following discharge of the patient (Brickner 2016, 84). A patient is admitted with an acute inferior myocardial infarction and discharged alive. Which condition would increase the MS-DRG weight? a. Respiratory failure b. Atrial fibrillation c. Hypertension d. History of myocardial infarction - ANSWERS- a. Respiratory failure RATIONALE :MS-DRG 280 (weight = 01.6577) for myocardial infarction with respiratory failure would change the MS-DRG. MS-DRG 282 (weight = 00.75863) would be assigned for myocardial infarction alone, with atrial fibrillation, with hypertension, and with history of myocardial infarction (Medicare Grouper Version 35). According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a: a. Proctosigmoidoscopy b. Sigmoidoscopy c. Colonoscopy d. Proctoscopy - ANSWERS- c. Colonoscopy RATIONALE :A colonoscopy is an examination of the entire colon, from the rectum to the cecum that may include the terminal ileum. In general, a colonoscopy examines the colon to a level of 60 cm or higher (Smith 2018, 135- 136). According to the UHDDS, in order to assign a code for another diagnosis, documentation must be present that: a. The condition is recorded in the patient record by a dietary clerk b. The condition is present in the admission department data c. The condition was clinically evaluated or therapeutically treated, extended
c. I24.8, Other forms of acute ischemic heart disease d. I24.0, Acute coronary thrombosis not resulting in myocardial infarction - ANSWERS- d. I24.0, Acute coronary thrombosis not resulting in myocardial infarction RATIONALE : Acute ischemic heart disease or acute myocardial ischemia in a patient does not always indicate an infarction. It is often possible to prevent infarction by means of surgery or the use of thrombolytic agents if the patient is treated promptly. Using the main term, ischemia, then the subterms of myocardium and acute, the alphabetic index reflects that I24.0 is the correct code for an acute myocardial ischemia without myocardial infarction (Leon- Chisen 2018, 391). After a patient is discharged from the hospital, the medical record must be reviewed for: a. Inclusion of all incident reports b. Certain basic reports (for example, history and physical, discharge summary, etc.) c. Voided prescription pads d. Personal case notes from all mental health providers - ANSWERS- b. Certain basic reports (for example, history and physical, discharge summary, etc.) In order to determine if a medical record is complete, it must be reviewed for certain basic reports including the presence of a history and physical, signed progress notes, and a discharge summary if applicable (Reynolds and Sharp 2016, 123 - 125). The incident report should never be filed in the medical record (Carter and Palmer 2016, 522); voided prescription pads are not used during a
patient hospitalization; personal case notes from mental health providers are kept separate from the official record. While there are a number of documents required for the hospital medical record to be complete, the ones described in option b present the best answer (Rinehart-Thompson 2017c, 189) 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 - ANSWERS- 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).
c. Malignant melanoma of the right forearm, benign breast cyst, and hypertension d. Malignant melanoma of the right forearm, benign breast cyst - ANSWERS- a. Malignant melanoma of forearm, hypertension Assign codes for malignant melanoma of forearm, hypertension. Code chronic conditions if they affect the patient's treatment. The hypertension was being treated with a current medication and for this reason the hypertension is coded (CMS 2018a, Section IV.A.1. and Section IV.J., 108-109). A patient is readmitted two weeks after a laminectomy for spinal stenosis with a headache and documentation that the headache is due to a tear in the dura accidently that occurred during the prior laminectomy surgery. The patient is taken to the operating room for repair of the dura. The diagnosis code(s) assigned for this admission would be: a. M48.061, Spinal stenosis, lumbar region, without neurogenic claudication b. G97.41, Accidental puncture or laceration of dura during a procedure c. G97.1, Other reaction to spinal and lumbar puncture d. S34.109A, Unspecified injury to unspecified level of lumbar spinal cord, initial encounter - ANSWERS- b. G97.41, Accidental puncture or laceration of dura during a procedure A tear in the dura that occurs during spinal surgery is not unusual and is typically repaired intraoperatively when identified. Primary closure of the dural tear is usually accomplished. Dural tears that are not discovered during surgery
can result in leakage of cerebrospinal fluid (CSF), leading to CSF headache, caudal displacement of the brain, subdural hematoma, spinal meningitis, pseudomeningocele and/or a dural cutaneous fistula (CMS 2018a, Section I.B.16, 18). During an admission for congestive heart failure (CHF), a chest x-ray was done to evaluate for the presence of CHF. An asymptomatic hernia was also found for which no treatment or evaluation was done. What is the reason that the hernia should not be coded? a. The patient's primary condition of interest is the CHF. b. The hernia is an incidental finding and does not meet the UHDDS requirements. c. The patient is asymptomatic. d. The condition does not impact the reimbursement. - ANSWERS- b. The hernia is an incidental finding and does not meet the UHDDS requirements. The hernia is an incidental finding. The condition does not meet the UHDDS criteria of an "other" condition (CMS 2018a, Section III, 105-106). A patient is admitted to the hospital due to a fracture of the right hip and is scheduled for an open reduction with internal fixation. The patient developed cardiac arrhythmia which results in an inability to do the planned surgery. Assign a code for the principal diagnosis.
a. Assign a code from the list of conditions in the history that occurred in the past b. Assign a code for the reason for the last visit to the ED c. Assign codes for abnormal laboratory findings d. Assign a code for the chief complaint as the reason for the visit - ANSWERS- d. Assign a code for the chief complaint as the reason for the visit In the absence of a diagnosis or defined problem, the chief compliant should be coded as the reason for the visit (CMS 2018a, Section IV.G., 109). 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 - ANSWERS- b. External cause codes for Cause of Injury, Place of Occurrence, Activity, and Status External cause of injury codes are used to provide information about how an injury occurred, the intent (intentional or unintentional), where the injury occurred, and the status of the person at the time the injury occurred. In the case
of a person who seeks care for an injury or other health condition that resulted from an activity, or when an activity contributed to the injury or health condition, activity codes are used to describe the activity (CMS 2018a, Section I.20., 81). A patient undergoes a colposcopy with endometrial biopsy. Which of the following is correct? a. b. The colposcopy and endometrial biopsy are represented by a combination code. c. Two codes would be used with modifier - 59 appended. d. Two codes would be used in accordance with CPT code instructions. e. Only one code is used and it does not state that it includes endometrial biopsy specifically.
- ANSWERS- c. Two codes would be used in accordance with CPT code instructions. The endometrial biopsy (58110) is an add-on code and there are specific directions in the CPT book to use this code in conjunction with the code for the colposcopy (CPT Assistant June 2006, 16-17). 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
Professional Edition 2018, 458). A patient is prescribed Diazepam and reports taking more than the prescribed amount. The patient is admitted to the hospital for complete work up. The final diagnosis is documented as Diazepam use and abuse. How should this be coded? a. F13. b. F13. c. F13. d. F13.11 - ANSWERS- c. F13.
Diazepam is a sedative. When use and abuse are documented, assign only the code for abuse (CMS 2018a, Section I.C.5.b.2., 37). According to the UHDDS, section III, the definition of other diagnoses is all conditions that: a. Coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay b. Receive evaluation and are documented by the physician c. Receive clinical evaluation, therapeutic treatment, further evaluation, extend the length of stay, increase nursing monitoring/care d. Are considered to be essential by the physicians involved and are reflected in the record - ANSWERS- a. Coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay The quality of data is most directly tied to the: a. Conditions treated in surrounding healthcare settings b. Surgical case review committee c. Length of hospital stay d. Use or application of the data - ANSWERS- d. Use or application of the data The use or application of the data and the purpose for the collection of the data is key to understanding its quality (Johns 2016, 84-85; Amatayakul 2016a,
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 - ANSWERS- 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 child has second- and third-degree burns of the left lower leg and second- and third-degree burns of the lower back with a total of 16 percent total body surface area (TBSA), 9 percent third-degree. What is the correct code assignment?
a. T24.301A, T21.34XA, T31. b. T24.302D, T21.34XD, T31. c. T24.302A, T21.34XA, T31. d. T24.301D, T21.34XD, T31.10 - ANSWERS- c. T24.302A, T21.34XA, T31. T24.302A, T21.34XA, T31.10, Burns classified to the same site but with different degrees are coded to the highest degree of burn (CMS 2018a, Section I.C.19.d.2, 75). An additional code for the extent of the body surface involved may also be assigned (CMS 2018a, Section I.C.19.d.6, 75). In CPT, unlisted codes are reported only if: a. There is not a current CPT category I code available b. There is not a current CPT category III code available c. There is not a current CPT category II code available d. There is not a HCPCS Level II code or a current CPT level III code - ANSWERS- d. There is not a HCPCS Level II code or a current CPT level III code Before any unlisted code is assigned, the coding professional should review HCPCS Level II (national) codes to confirm that CMS has not developed a
b. J96. c. O88. d. O88.22 - ANSWERS- a. O88. The obstetric code is sequenced first because chapter 15 (obstetric) codes have sequencing priority over codes from other ICD- 10 - CM chapters (CMS 2018a, Section I.C.15.a.1, 56). A maternity patient is admitted in labor at 43 weeks. She has a normal delivery with vacuum extraction to facilitate the baby's delivery. Which of the following would be the principal diagnosis? O80 Encounter for full-term uncomplicated delivery
O48.0 Post-term pregnancy O48.1 Prolonged pregnancy O66.5 Attempted application of vacuum extractor and forceps a. O48. b. O48. c. O d. O66.5 - ANSWERS- b. O48. When an admission involves delivery, the principal diagnosis should identify the main circumstance or complication of the delivery. The code for normal delivery cannot be used because there is a complication of pregnancy because the pregnancy is prolonged (CMS 2018a, Section I.C.15.b., 59). If a patient has undergone an outpatient echocardiogram and the cardiologist concludes in the report that the patient has mitral regurgitation, the coder should: a. Assign a diagnostic code for mitral regurgitation b. Query the physician about the diagnosis
