Certified Clinical Documentation Specialist
(CCDS) | 100 Exam Questions with Answers |
Diagnosis Coding, CDI Queries, MS-DRG, Metrics
Health Information Management
Section 1: Principal Diagnosis Selection and Sequencing (Q1-20)
1. A patient is admitted from the emergency department (ED) with a
diagnosis of weakness and anemia. After admission and further treatment
with packed red blood cells (PRBC), GI consult, and endoscopy, the
physician includes the following diagnoses in the discharge summary:
anemia, suspected bleeding gastric ulcer, and GERD. What would be the
most appropriate principal diagnosis?
Answer: A. Bleeding gastric ulcer
Rationale: The bleeding gastric ulcer is the underlying condition that caused the
anemia and weakness. It was diagnosed and treated during the admission (via
endoscopy and PRBCs). Coding guidelines prioritize the condition that was chiefly
responsible for the admission and subsequent treatment .
2. A patient is admitted with new-onset seizures. Head CT reveals a mass in
the occipital region. The physician documents "possible brain tumor," and
the patient is transferred to another hospital for further workup. What
would be the most appropriate principal diagnosis based upon this
documentation?
Answer: B. Neoplasm of occipital region
Rationale: The mass found on CT is the definitive finding driving the admission
and transfer. "Possible" diagnoses are coded if definitively stated at the time of
discharge/transfer. The neoplasm is more specific than the symptom (seizure) or
nonspecific terms (head mass/tumor) .
,3. A patient is admitted from the emergency department with the diagnosis
of acute respiratory failure due to overdose of pain medication and an
aspiration pneumonia. What is the principal diagnosis?
Answer: C. Poisoning
Rationale: Per coding guidelines, when a patient is admitted due to an adverse
effect or poisoning, the poisoning is sequenced first, followed by the
manifestation (respiratory failure, pneumonia) .
4. A patient is admitted with pneumonia, stage 1 chronic renal failure, chronic
anemia, and COPD. While hospitalized, the patient receives IV antibiotics,
inhalers, oxygen, IV fluids at 50mL/hr, and iron tablets. Keeping the
guidelines for coding of secondary diagnoses in mind, which condition
should be coded?
Answer: D. All of the conditions should be coded
Rationale: All conditions that affect patient care, treatment, or length of stay
should be coded. Chronic renal failure (even stage 1), chronic anemia (treated
with iron), and COPD (treated with inhalers) all required monitoring or
management during the stay .
5. A patient is admitted with abdominal pain, and the history and physical
indicated a diagnosis of probable colon cancer. On day two, the physician
documents acute renal failure in the progress notes, and the patient
receives IV fluids. The discharge summary lists possible metastatic colon
cancer and acute renal failure. The principal diagnosis would be:
Answer: A. Colon cancer
Rationale: The colon cancer is the underlying condition that caused the
admission. The acute renal failure was a developing condition during the stay, but
the cancer remains the reason for admission. "Probable" at admission becomes
coded if documented at discharge .
6. A patient with a history of metastatic lung cancer is directly admitted from
the doctor's office with a diagnosis of anemia secondary to chemotherapy.
The patient receives two units of PRBCs and is discharged. What is the
most appropriate principal diagnosis? Answer: B. Anemia
, Rationale: The anemia was the reason for admission and required active
treatment (blood transfusion). The anemia is directly linked to chemotherapy, but
the admission was specifically for the anemia, not the cancer or the
chemotherapy administration .
7. A patient is admitted from the ED with rectal bleeding secondary to
Coumadin toxicity. The physician documents that the patient had a recent
increase in Coumadin dosage due to low PT/PTT. The patient also has a
history of COPD and CHF. What is the most appropriate principal diagnosis?
Answer: A. GI hemorrhage
Rationale: The GI hemorrhage (rectal bleeding) is the acute condition requiring
admission. Coumadin toxicity is the cause, but the bleeding is the reason for
admission and the condition that required immediate management .
8. A patient comes to the ED with fever, chills, and knee pain. Documentation
states that the patient's admission is for knee prosthesis removal due to
infection. What is the principal diagnosis? (Do not include the procedure)
Answer: C. Infected knee prosthesis
Rationale: The infection of the prosthesis is the underlying condition requiring
the removal. The fever and pain are symptoms of the infection .
9. A patient is admitted with pain in the lower extremity. The physician
documents cellulitis due to septic joint. X-ray indicates possible
osteomyelitis. What is the principal diagnosis?
Answer: D. Septic joint
Rationale: The septic joint is the underlying infectious condition causing both the
pain and the cellulitis. It is the most definitive diagnosis documented .
10. A patient is admitted with hypertensive heart failure and chronic kidney
disease (CKD). Appropriate code assignment would:
Answer: D. Utilize a combination code with the individual codes listed as
secondary
Rationale: ICD-10 provides combination codes (I13.x) for hypertensive heart and
chronic kidney disease. The combination code captures the relationship, and
individual codes provide specificity .
(CCDS) | 100 Exam Questions with Answers |
Diagnosis Coding, CDI Queries, MS-DRG, Metrics
Health Information Management
Section 1: Principal Diagnosis Selection and Sequencing (Q1-20)
1. A patient is admitted from the emergency department (ED) with a
diagnosis of weakness and anemia. After admission and further treatment
with packed red blood cells (PRBC), GI consult, and endoscopy, the
physician includes the following diagnoses in the discharge summary:
anemia, suspected bleeding gastric ulcer, and GERD. What would be the
most appropriate principal diagnosis?
Answer: A. Bleeding gastric ulcer
Rationale: The bleeding gastric ulcer is the underlying condition that caused the
anemia and weakness. It was diagnosed and treated during the admission (via
endoscopy and PRBCs). Coding guidelines prioritize the condition that was chiefly
responsible for the admission and subsequent treatment .
2. A patient is admitted with new-onset seizures. Head CT reveals a mass in
the occipital region. The physician documents "possible brain tumor," and
the patient is transferred to another hospital for further workup. What
would be the most appropriate principal diagnosis based upon this
documentation?
Answer: B. Neoplasm of occipital region
Rationale: The mass found on CT is the definitive finding driving the admission
and transfer. "Possible" diagnoses are coded if definitively stated at the time of
discharge/transfer. The neoplasm is more specific than the symptom (seizure) or
nonspecific terms (head mass/tumor) .
,3. A patient is admitted from the emergency department with the diagnosis
of acute respiratory failure due to overdose of pain medication and an
aspiration pneumonia. What is the principal diagnosis?
Answer: C. Poisoning
Rationale: Per coding guidelines, when a patient is admitted due to an adverse
effect or poisoning, the poisoning is sequenced first, followed by the
manifestation (respiratory failure, pneumonia) .
4. A patient is admitted with pneumonia, stage 1 chronic renal failure, chronic
anemia, and COPD. While hospitalized, the patient receives IV antibiotics,
inhalers, oxygen, IV fluids at 50mL/hr, and iron tablets. Keeping the
guidelines for coding of secondary diagnoses in mind, which condition
should be coded?
Answer: D. All of the conditions should be coded
Rationale: All conditions that affect patient care, treatment, or length of stay
should be coded. Chronic renal failure (even stage 1), chronic anemia (treated
with iron), and COPD (treated with inhalers) all required monitoring or
management during the stay .
5. A patient is admitted with abdominal pain, and the history and physical
indicated a diagnosis of probable colon cancer. On day two, the physician
documents acute renal failure in the progress notes, and the patient
receives IV fluids. The discharge summary lists possible metastatic colon
cancer and acute renal failure. The principal diagnosis would be:
Answer: A. Colon cancer
Rationale: The colon cancer is the underlying condition that caused the
admission. The acute renal failure was a developing condition during the stay, but
the cancer remains the reason for admission. "Probable" at admission becomes
coded if documented at discharge .
6. A patient with a history of metastatic lung cancer is directly admitted from
the doctor's office with a diagnosis of anemia secondary to chemotherapy.
The patient receives two units of PRBCs and is discharged. What is the
most appropriate principal diagnosis? Answer: B. Anemia
, Rationale: The anemia was the reason for admission and required active
treatment (blood transfusion). The anemia is directly linked to chemotherapy, but
the admission was specifically for the anemia, not the cancer or the
chemotherapy administration .
7. A patient is admitted from the ED with rectal bleeding secondary to
Coumadin toxicity. The physician documents that the patient had a recent
increase in Coumadin dosage due to low PT/PTT. The patient also has a
history of COPD and CHF. What is the most appropriate principal diagnosis?
Answer: A. GI hemorrhage
Rationale: The GI hemorrhage (rectal bleeding) is the acute condition requiring
admission. Coumadin toxicity is the cause, but the bleeding is the reason for
admission and the condition that required immediate management .
8. A patient comes to the ED with fever, chills, and knee pain. Documentation
states that the patient's admission is for knee prosthesis removal due to
infection. What is the principal diagnosis? (Do not include the procedure)
Answer: C. Infected knee prosthesis
Rationale: The infection of the prosthesis is the underlying condition requiring
the removal. The fever and pain are symptoms of the infection .
9. A patient is admitted with pain in the lower extremity. The physician
documents cellulitis due to septic joint. X-ray indicates possible
osteomyelitis. What is the principal diagnosis?
Answer: D. Septic joint
Rationale: The septic joint is the underlying infectious condition causing both the
pain and the cellulitis. It is the most definitive diagnosis documented .
10. A patient is admitted with hypertensive heart failure and chronic kidney
disease (CKD). Appropriate code assignment would:
Answer: D. Utilize a combination code with the individual codes listed as
secondary
Rationale: ICD-10 provides combination codes (I13.x) for hypertensive heart and
chronic kidney disease. The combination code captures the relationship, and
individual codes provide specificity .
