CCS DOMAIN 2 MOCK EXAM 4
QUESTIONS AND ANSWERS 2026
AHIMA guidelines state a query should be considered when health
record documentation includes which of the following?
A diagnosis without an underlying clinical validation
Conflicting, imprecise, incomplete, ambiguous, or inconsistent
documentation
Unclear POA (present on admission) indicators
All of these -
correct answer ✅All of these
AHIMA guidelines state that a query should be considered when
health record documentation includes the following:
Conflicting, imprecise, incomplete, ambiguous, or inconsistent
documentation
Associated clinical indicators related to a specific condition
A diagnosis without an underlying clinical validation
Unclear POA (present on admission) indicators
Based on the following documentation, where you would expect
this excerpt to appear?
The patient is alert and in no acute distress. Initial vital signs: T98, P
102 and regular, R 20 and BP 120/69...
chief complaint
,CCS DOMAIN 2 MOCK EXAM 4
QUESTIONS AND ANSWERS 2026
past medical history
physical exam
social history -
correct answer ✅physical exam
Past medical history, social history, and chief complaint represent
components of the medical history as supplied by the patient, while
the physical exam is an entry obtained through objective
observation and measurement made by the provider.
A coder notes that a patient is taking prescription pilocarpine. The
final diagnoses on the discharge summary are congestive heart
failure and diabetes mellitus. The coder should query the physician
about adding a diagnosis of
glaucoma.
arthritis.
laryngitis.
bronchitis. -
correct answer ✅glaucoma
As eye drops, pilocarpine is used for angle closure glaucoma until
surgery can be performed, ocular hypertension, open angle
glaucoma, and to bring about constriction of the pupil following its
dilation. It should also be noted that coders are prohibited from
,CCS DOMAIN 2 MOCK EXAM 4
QUESTIONS AND ANSWERS 2026
performing assumption coding, which is the assignment of codes
based on assuming, from a review of clinical evidence in the
patient's record, that the patient has a certain diagnosis or received
certain procedures/services even though the provider did not
specifically document the diagnosis or procedures/services. In this
case, coders should query the physician before coding the
glaucoma diagnosis.
An 89-year-old male is admitted to a nursing home with confusion,
hypotension, a temperature of 103.5, and obvious dehydration.
Blood cultures were negative; however, urine culture was positive
for Escherichia coli. Physician documents final diagnosis as
septicemia, septic shock, UTI due to E. coli, and dehydration. (Code
the ICD-10-CM diagnoses.)
N39.0, A41.9, B96.20, E86.0, R65.21, F29
A41.9, R65.21, N39.0, B96.20, E86.0
A41.9, E86.0, B96.20, R50.9, R65.21, F29
N39.0, I95.9, B96.20, R50.9, E86.0, F29 -
correct answer ✅A41.9, R65.21, N39.0, B96.20, E86.0
The
correct answer is A41.9, R65.21, N39.0, B96.20, E86.0. See ICD-10-
CM Official Guidelines for Coding and Reporting 2018, Section
1.c.1.d.1, Coding of Sepsis and Severe Sepsis.
, CCS DOMAIN 2 MOCK EXAM 4
QUESTIONS AND ANSWERS 2026
Which diagnostic technique records the patient's heart rates and
rhythms over a 24-hour period?
electrocardiography
angiocardiography
Holter monitor
echocardiography -
correct answer ✅Holter monitor
The holter monitor records your heart's activity (ECG) continuously
for 24-48 hours.
In addition to diagnostic and therapeutic orders from the attending
physician, you would expect every completed inpatient health
record to contain
telephone orders.
discharge order.
stop orders.
standing orders. -
correct answer ✅discharge order
Although many patient health records may feasibly contain all of
the orders listed, only the discharge order is required to document
QUESTIONS AND ANSWERS 2026
AHIMA guidelines state a query should be considered when health
record documentation includes which of the following?
A diagnosis without an underlying clinical validation
Conflicting, imprecise, incomplete, ambiguous, or inconsistent
documentation
Unclear POA (present on admission) indicators
All of these -
correct answer ✅All of these
AHIMA guidelines state that a query should be considered when
health record documentation includes the following:
Conflicting, imprecise, incomplete, ambiguous, or inconsistent
documentation
Associated clinical indicators related to a specific condition
A diagnosis without an underlying clinical validation
Unclear POA (present on admission) indicators
Based on the following documentation, where you would expect
this excerpt to appear?
The patient is alert and in no acute distress. Initial vital signs: T98, P
102 and regular, R 20 and BP 120/69...
chief complaint
,CCS DOMAIN 2 MOCK EXAM 4
QUESTIONS AND ANSWERS 2026
past medical history
physical exam
social history -
correct answer ✅physical exam
Past medical history, social history, and chief complaint represent
components of the medical history as supplied by the patient, while
the physical exam is an entry obtained through objective
observation and measurement made by the provider.
A coder notes that a patient is taking prescription pilocarpine. The
final diagnoses on the discharge summary are congestive heart
failure and diabetes mellitus. The coder should query the physician
about adding a diagnosis of
glaucoma.
arthritis.
laryngitis.
bronchitis. -
correct answer ✅glaucoma
As eye drops, pilocarpine is used for angle closure glaucoma until
surgery can be performed, ocular hypertension, open angle
glaucoma, and to bring about constriction of the pupil following its
dilation. It should also be noted that coders are prohibited from
,CCS DOMAIN 2 MOCK EXAM 4
QUESTIONS AND ANSWERS 2026
performing assumption coding, which is the assignment of codes
based on assuming, from a review of clinical evidence in the
patient's record, that the patient has a certain diagnosis or received
certain procedures/services even though the provider did not
specifically document the diagnosis or procedures/services. In this
case, coders should query the physician before coding the
glaucoma diagnosis.
An 89-year-old male is admitted to a nursing home with confusion,
hypotension, a temperature of 103.5, and obvious dehydration.
Blood cultures were negative; however, urine culture was positive
for Escherichia coli. Physician documents final diagnosis as
septicemia, septic shock, UTI due to E. coli, and dehydration. (Code
the ICD-10-CM diagnoses.)
N39.0, A41.9, B96.20, E86.0, R65.21, F29
A41.9, R65.21, N39.0, B96.20, E86.0
A41.9, E86.0, B96.20, R50.9, R65.21, F29
N39.0, I95.9, B96.20, R50.9, E86.0, F29 -
correct answer ✅A41.9, R65.21, N39.0, B96.20, E86.0
The
correct answer is A41.9, R65.21, N39.0, B96.20, E86.0. See ICD-10-
CM Official Guidelines for Coding and Reporting 2018, Section
1.c.1.d.1, Coding of Sepsis and Severe Sepsis.
, CCS DOMAIN 2 MOCK EXAM 4
QUESTIONS AND ANSWERS 2026
Which diagnostic technique records the patient's heart rates and
rhythms over a 24-hour period?
electrocardiography
angiocardiography
Holter monitor
echocardiography -
correct answer ✅Holter monitor
The holter monitor records your heart's activity (ECG) continuously
for 24-48 hours.
In addition to diagnostic and therapeutic orders from the attending
physician, you would expect every completed inpatient health
record to contain
telephone orders.
discharge order.
stop orders.
standing orders. -
correct answer ✅discharge order
Although many patient health records may feasibly contain all of
the orders listed, only the discharge order is required to document
