CCS-CERTIFIED CODING SPECIALIST EXAM 2 n n n n
| (WITH RATIONALES) NEWEST ACTUAL EX
n n n n n
AM COMPREHENSIVE QUESTIONS AND VE
n n n n
RIFIED ANSWERS GRADED A+ | 100% CORR n n n n n n
ECT | 2024 UPDATE!! n n n
A patient was admitted with hyperglycemia, uncontrolled thirst,
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constant hunger, and weight gain. Testing indicates that the pati
n n n n n n n n n
ent has Type 2 diabetes which is noted in the discharge summary.
n n n n n n n n n n n
What is the POA indicator for the diabetes?
n n n n n n n n
a. Y
b. N
c. U
d. W - ✔✔✔ Correct Answer > Correct Answer: A
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Chronic conditions should have a POA indicator of Y, even if they
n n n n n n n n n n n n
are diagnosed after admission (CMS 2020a, 117-121)
n n n n n n
A condition that is established after study to be chiefly responsibl
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e for the admission is the:
n n n n n
a. Reason for visit n n
,b. Principal procedure n
c. A complication of outpatient care
n n n n
d. Principal diagnosis - n n
✔✔✔ Correct Answer > Correct Answer: D
n n n n n n n
The principal diagnosis is defined as the condition "established af
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ter study to be chiefly responsible for occasioning the admission
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of the patient to the hospital for care." Selecting the principal dia
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gnosis depends on the circumstances of the admission and why t
n n n n n n n n n n
he patient was admitted (Schraffenberger and Palkie 2020, 92; C
n n n n n n n n n
MS 2020a, Section II, 107).
n n n n
A patient is admitted to the hospital with a high fever, chills, tach
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ycardia, and a respiration rate of 26. Lactic acidosis is noted in the
n n n n n n n n n n n n n
labs. Pneumonia is diagnosed and the patient admitted to ICU wh
n n n n n n n n n n
ere antibiotics are given along with Levophed to help maintain th
n n n n n n n n n n
e patient's blood pressure which was in the extremely low range.
n n n n n n n n n n n
The patient's breathing was erratic and mechanical ventilation w
n n n n n n n n
as initiated. With a final diagnosis of pneumonia, what is the quer
n n n n n n n n n n n
y opportunity for this record?
n n n n
a. Is this aspiration pneumonia?
n n n
b. Is this septic shock?
n n n
c. Is this Staphylococcus aureus pneumonia?
n n n n
d. Is this sepsis? - ✔✔✔ Correct Answer > Correct Answer: B
n n n n n n n n n n
,The clinical indicators of fever, chills, tachycardia, tachypnea, and
n n n n n n n n n
lactic acidosis all point to sepsis, but with the addition of respirato
n n n n n n n n n n n
ry issues requiring mechanical ventilation, and circulatory failure
n n n n n n n n
requiring the use of vasopressors, this condition more likely repre
n n n n n n n n n
sents septic shock and should be queried (Schraffenberger and Pa
n n n n n n n n n
lkie 2020, 122-123).
n n
Two areas of documentation in the health record that are signific
n n n n n n n n n n
ant areas of focus of accrediting agencies are:
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a. Incident reports notation in the medical record and a
n n n n n n n n
ttorney's notes n
b. Past medical reports and social worker's notes
n n n n n n
c. Timeliness and legibility of medical documents n n n n n
d. Patient documentation and pastoral counseling - ✔✔✔
n n n n n n
Correct Answer > Correct Answer: C
n n n n n
There are many areas that accrediting agencies review but timeli
n n n n n n n n n
ness and legibility of medical documents are two of the most imp
n n n n n n n n n n n
ortant aspects of health record management (Johns 2020, 85; C
n n n n n n n n n
MS 2011, 2).
n n
Which of the following is not a function of the outpatient code ed
n n n n n n n n n n n n
itor (OCE)?
n
a. Editing the data on the claim for accuracy
n n n n n n n
, b. Specifying the action the FI should take when specific edits o n n n n n n n n n n
ccur
c. Assigning APCs to the claim (for hospital outpatient services)
n n n n n n n n
d. Determining payment- n
related conditions that require direct reference to ICD-10-
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CM codes - ✔✔✔ Correct Answer > Correct Answer: D
n n n n n n n n n
The outpatient code editor (OCE) performs four basic functions: e
n n n n n n n n n
diting the data on the claim for accuracy, specifying the action the
n n n n n n n n n n n
fiscal intermediary should take when specific edits occur, assigni
n n n n n n n n n
ng APCs to the claim (for hospital outpatient services), and deter
n n n n n n n n n n
mining payment- n
related conditions that require direct reference to HCPCS codes o
n n n n n n n n n
r modifiers (Smith 2020, 314-315).
n n n n
A patient comes into the hospital with chest pain, shortness of br
n n n n n n n n n n n
eath, and a history of COPD. An MRI, chest x-
n n n n n n n n n
ray, troponin, and CKMB are ordered. A coder might expect a me
n n n n n n n n n n n
dical necessity edit to be triggered for which test?
n n n n n n n n
a. Troponin
b. Chest x-ray n
c. MRI
d. CKMB - ✔✔✔ Correct Answer > Correct Answer: C
n n n n n n n n
| (WITH RATIONALES) NEWEST ACTUAL EX
n n n n n
AM COMPREHENSIVE QUESTIONS AND VE
n n n n
RIFIED ANSWERS GRADED A+ | 100% CORR n n n n n n
ECT | 2024 UPDATE!! n n n
A patient was admitted with hyperglycemia, uncontrolled thirst,
n n n n n n n n
constant hunger, and weight gain. Testing indicates that the pati
n n n n n n n n n
ent has Type 2 diabetes which is noted in the discharge summary.
n n n n n n n n n n n
What is the POA indicator for the diabetes?
n n n n n n n n
a. Y
b. N
c. U
d. W - ✔✔✔ Correct Answer > Correct Answer: A
n n n n n n n n
Chronic conditions should have a POA indicator of Y, even if they
n n n n n n n n n n n n
are diagnosed after admission (CMS 2020a, 117-121)
n n n n n n
A condition that is established after study to be chiefly responsibl
n n n n n n n n n n
e for the admission is the:
n n n n n
a. Reason for visit n n
,b. Principal procedure n
c. A complication of outpatient care
n n n n
d. Principal diagnosis - n n
✔✔✔ Correct Answer > Correct Answer: D
n n n n n n n
The principal diagnosis is defined as the condition "established af
n n n n n n n n n
ter study to be chiefly responsible for occasioning the admission
n n n n n n n n n n
of the patient to the hospital for care." Selecting the principal dia
n n n n n n n n n n n
gnosis depends on the circumstances of the admission and why t
n n n n n n n n n n
he patient was admitted (Schraffenberger and Palkie 2020, 92; C
n n n n n n n n n
MS 2020a, Section II, 107).
n n n n
A patient is admitted to the hospital with a high fever, chills, tach
n n n n n n n n n n n n
ycardia, and a respiration rate of 26. Lactic acidosis is noted in the
n n n n n n n n n n n n n
labs. Pneumonia is diagnosed and the patient admitted to ICU wh
n n n n n n n n n n
ere antibiotics are given along with Levophed to help maintain th
n n n n n n n n n n
e patient's blood pressure which was in the extremely low range.
n n n n n n n n n n n
The patient's breathing was erratic and mechanical ventilation w
n n n n n n n n
as initiated. With a final diagnosis of pneumonia, what is the quer
n n n n n n n n n n n
y opportunity for this record?
n n n n
a. Is this aspiration pneumonia?
n n n
b. Is this septic shock?
n n n
c. Is this Staphylococcus aureus pneumonia?
n n n n
d. Is this sepsis? - ✔✔✔ Correct Answer > Correct Answer: B
n n n n n n n n n n
,The clinical indicators of fever, chills, tachycardia, tachypnea, and
n n n n n n n n n
lactic acidosis all point to sepsis, but with the addition of respirato
n n n n n n n n n n n
ry issues requiring mechanical ventilation, and circulatory failure
n n n n n n n n
requiring the use of vasopressors, this condition more likely repre
n n n n n n n n n
sents septic shock and should be queried (Schraffenberger and Pa
n n n n n n n n n
lkie 2020, 122-123).
n n
Two areas of documentation in the health record that are signific
n n n n n n n n n n
ant areas of focus of accrediting agencies are:
n n n n n n n
a. Incident reports notation in the medical record and a
n n n n n n n n
ttorney's notes n
b. Past medical reports and social worker's notes
n n n n n n
c. Timeliness and legibility of medical documents n n n n n
d. Patient documentation and pastoral counseling - ✔✔✔
n n n n n n
Correct Answer > Correct Answer: C
n n n n n
There are many areas that accrediting agencies review but timeli
n n n n n n n n n
ness and legibility of medical documents are two of the most imp
n n n n n n n n n n n
ortant aspects of health record management (Johns 2020, 85; C
n n n n n n n n n
MS 2011, 2).
n n
Which of the following is not a function of the outpatient code ed
n n n n n n n n n n n n
itor (OCE)?
n
a. Editing the data on the claim for accuracy
n n n n n n n
, b. Specifying the action the FI should take when specific edits o n n n n n n n n n n
ccur
c. Assigning APCs to the claim (for hospital outpatient services)
n n n n n n n n
d. Determining payment- n
related conditions that require direct reference to ICD-10-
n n n n n n n
CM codes - ✔✔✔ Correct Answer > Correct Answer: D
n n n n n n n n n
The outpatient code editor (OCE) performs four basic functions: e
n n n n n n n n n
diting the data on the claim for accuracy, specifying the action the
n n n n n n n n n n n
fiscal intermediary should take when specific edits occur, assigni
n n n n n n n n n
ng APCs to the claim (for hospital outpatient services), and deter
n n n n n n n n n n
mining payment- n
related conditions that require direct reference to HCPCS codes o
n n n n n n n n n
r modifiers (Smith 2020, 314-315).
n n n n
A patient comes into the hospital with chest pain, shortness of br
n n n n n n n n n n n
eath, and a history of COPD. An MRI, chest x-
n n n n n n n n n
ray, troponin, and CKMB are ordered. A coder might expect a me
n n n n n n n n n n n
dical necessity edit to be triggered for which test?
n n n n n n n n
a. Troponin
b. Chest x-ray n
c. MRI
d. CKMB - ✔✔✔ Correct Answer > Correct Answer: C
n n n n n n n n
