CCS Exam Preparation, Domain 2:
Coding Documentation Questions &
Answers (Grade A+)
A 28-year-old male with a history of IV heroin dependence is
admitted for pneumonia. A pulmonologist is consulted to assist
with the patient's treatment and an antibiotic for Pneumocystis
carinii pneumonia is administered. Low potassium is treated as
well. The final diagnoses were coded as: B20, B59, E87.6, and
F11.21. What is the discrepancy noted between the coding and the
documentation?
A. The "history of" code reflects abuse rather than dependence
B. The correct code for the pneumonia should be J18.9
C. The assignment of B20 has no supportive documentation
D. The hypokalemia should not be coded as that is integral to the
pneumonia -
correct answer ✅C. The assignment of B20 has no supportive
documentation.
The diagnosis of HIV (B20) has no supporting diagnosis
documented. In this case a query would be appropriate to
,CCS Exam Preparation, Domain 2:
Coding Documentation Questions &
Answers (Grade A+)
determine if the patient has HIV since he is a previous IV drug user
and the type of pneumonia is often seen in patients with an HIV
diagnosis (Schraffenberger and Palkie 2022, 127-131).
A patient was admitted with pneumonia. A sputum culture was
able to identify Mycoplasma pneumoniae, which the consulting
pulmonologist documented as the cause of the pneumonia. The
patient was also diagnosed with an E. coli UTI. In the final diagnosis
statement, the attending physician documents E. coli pneumonia
and UTI. How will the coding professional code the pneumonia?
Assign the code based on the final diagnostic statement.
Assign the pneumonia code based on the consultant's
documentation.
Assign the pneumonia code based on the sputum result.
Query the attending provider to clarify the pneumonia organism. -
correct answer ✅Query the attending provider to clarify the
pneumonia organism.
, CCS Exam Preparation, Domain 2:
Coding Documentation Questions &
Answers (Grade A+)
An operative report indicates the physician performed metatarsal
surgery but all other information in the health record points to
need for metacarpal surgery. What step should the coding
professional take upon this discovery?
A. Code the metatarsal surgery as that is what is documented in the
operative report.
B. Code the metacarpal surgery since the op report was clearly an
error.
C. Query the physician to determine which body area the surgery
involved.
D. Suspend the chart and contact the coding supervisor as to which
procedure to code. -
correct answer ✅C. Query the physician to determine which body
area the surgery involved.
When there is conflicting information in the patient record, the
coding professional should query the physician for clarification
(AHIMA 2022).
Coding Documentation Questions &
Answers (Grade A+)
A 28-year-old male with a history of IV heroin dependence is
admitted for pneumonia. A pulmonologist is consulted to assist
with the patient's treatment and an antibiotic for Pneumocystis
carinii pneumonia is administered. Low potassium is treated as
well. The final diagnoses were coded as: B20, B59, E87.6, and
F11.21. What is the discrepancy noted between the coding and the
documentation?
A. The "history of" code reflects abuse rather than dependence
B. The correct code for the pneumonia should be J18.9
C. The assignment of B20 has no supportive documentation
D. The hypokalemia should not be coded as that is integral to the
pneumonia -
correct answer ✅C. The assignment of B20 has no supportive
documentation.
The diagnosis of HIV (B20) has no supporting diagnosis
documented. In this case a query would be appropriate to
,CCS Exam Preparation, Domain 2:
Coding Documentation Questions &
Answers (Grade A+)
determine if the patient has HIV since he is a previous IV drug user
and the type of pneumonia is often seen in patients with an HIV
diagnosis (Schraffenberger and Palkie 2022, 127-131).
A patient was admitted with pneumonia. A sputum culture was
able to identify Mycoplasma pneumoniae, which the consulting
pulmonologist documented as the cause of the pneumonia. The
patient was also diagnosed with an E. coli UTI. In the final diagnosis
statement, the attending physician documents E. coli pneumonia
and UTI. How will the coding professional code the pneumonia?
Assign the code based on the final diagnostic statement.
Assign the pneumonia code based on the consultant's
documentation.
Assign the pneumonia code based on the sputum result.
Query the attending provider to clarify the pneumonia organism. -
correct answer ✅Query the attending provider to clarify the
pneumonia organism.
, CCS Exam Preparation, Domain 2:
Coding Documentation Questions &
Answers (Grade A+)
An operative report indicates the physician performed metatarsal
surgery but all other information in the health record points to
need for metacarpal surgery. What step should the coding
professional take upon this discovery?
A. Code the metatarsal surgery as that is what is documented in the
operative report.
B. Code the metacarpal surgery since the op report was clearly an
error.
C. Query the physician to determine which body area the surgery
involved.
D. Suspend the chart and contact the coding supervisor as to which
procedure to code. -
correct answer ✅C. Query the physician to determine which body
area the surgery involved.
When there is conflicting information in the patient record, the
coding professional should query the physician for clarification
(AHIMA 2022).
