NEW CCS REAL EXAM QUESTIONS AND
ANSWERS TESTED AND APPROVED!!!
A patient was discharged from the same-day-surgery unit with the following diagnoses:
posterior subcapsular, mature, incipient, senile cataract right eye, diabetes mellitus,
hypertension, and was treated for mild acute renal failure. Which codes are correct?
E11.36Type 2 diabetes mellitus with diabetic cataract
E11.29Type 2 diabetes mellitus with other diabetic kidney complication
E11.9Type 2 diabetes mellitus without complications
H25.9Unspecified age-related cataract
H25.21Age-related cataract, morgagnian type, right eye
H25.041Posterior subcapsular polar age-related cataract, right eyeI10Essential hypertension
I12.9Hypertensive chronic kidney disease with stage 1 through stage 4, or unspecified
chronic kidney disease
N17.9Acute kidney failure, unspecified
a. H25.21, E11.29, I12.9, N17.9
b. E11.36, H25.041, I10, N17.9
c. H25.9, E11.29, I12.9, N17.9
d. H25.041, E11.9, I12.9 Correct Answer: B
The patient has posterior subcapsular, mature, incipient, senile cataract right eye, diabetes
mellitus, hypertension, acute renal failure. The hypertension and diabetes are not related to
Page 1 of 44
,the renal failure as it is acute and not chronic. Because of this, no combination code is
assigned for hypertension, diabetes and chronic renal failure. However, the diabetes and
cataract are related conditions which are coded using a combination code. The classification
presumes a relationship between diabetes and cataracts (CMS 2020a, Sections I.A.15, 12-13
and I.B.9., 15; AHA Coding Clinic 2016 2nd Quarter, 36-37; AHA Coding Clinic 2019 2nd
Quarter, 30).
145
Correct0
Wrong1
Unanswered45
Current Procedural Terminology (CPT) defines a separate procedure as which of the
following?
a. Procedure considered an integral part of a more major service
b. Provision of anesthesia
c. Procedure that requires an add-on code
d. A surgical procedure performed in conjunction with an E&M visit Correct Answer: A
When a procedure is designated as a separate procedure in the CPT code book and it is
performed in conjunction with another service, it is considered an integral part of the major
service. The CPT code description includes "separate procedure." The intention is not to
provide payment for a procedure that is already integral to any given procedure (Smith 2020,
68-69; AMA CPT Professional Edition 2020, 72-73).
Documentation from the nursing or other allied health professionals' notes can be used to
provide specificity for code assignment for which of the following diagnoses?
Page 2 of 44
,a. Body mass index (BMI)
b. Malnutrition
c. Aspiration pneumonia
d. Fatigue Correct Answer: A
The physician must establish the diagnosis—obesity or morbid obesity—and the additional
information can be pulled from ancillary documentation to establish the correct code
assignment for body mass index (BMI) (CMS 2020a, Section I.B.14, 17-18).
A laparoscopic cholecystectomy was performed. What is the correct ICD-10-PCS code?
0FB40ZZExcision of gallbladder, open approach
0FB44ZZExcision of gallbladder, percutaneous endoscopic approach
0FT40ZZResection of gallbladder, open approach
0FT44ZZResection of gallbladder, percutaneous endoscopic approach
a. 0FB40ZZ
b. 0FT40ZZ
c. 0FT44ZZ
d. 0FB44ZZ Correct Answer: C
A cholecystectomy includes complete removal of the gallbladder; therefore, the correct root
operation is Resection. Since the procedure is specified as a laparoscopic cholecystectomy,
the approach is percutaneous endoscopic (Leon-Chisen 2020, 247-248).
Page 3 of 44
, Carcinoma of multiple overlapping sites of the bladder. Diagnostic cystoscopy and
transurethral fulguration of bladder lesions over the dome and posterior wall (1.9 cm.) was
completed. A biopsy was taken of a lesion in the lateral wall. What modifier should be added
to the biopsy procedure code?
a. -50, Bilateral procedure
b. -51, Multiple procedures
c. -59, Distinct procedural service
d. -99, Multiple modifiers Correct Answer: C
The surgery is done on two distinct areas within the bladder with two distinct approaches.
The biopsy is not of the area that was resected and warrants the use of -59 (CPT Assistant
Sept. 2001; CPT Professional Edition 2020, Appendix A).
A bronchoscopy with multiple biopsies of the left bronchus was completed and revealed
adenocarcinoma. What, if any, modifier should be added to the procedure code billed by the
facility?
a. -59, Distinct procedural service
b. -51, Multiple procedures
c. -76, Repeat procedure or service by same physician
d. No modifiers should be reported Correct Answer: D
The procedure is reported with code 31625, the description of which indicates biopsy of
single or multiple sites. When reporting this code, it is not necessary to indicate multiple
procedures as the code itself does that (AMA CPT Professional Edition 2020, Appendix A).
Page 4 of 44
ANSWERS TESTED AND APPROVED!!!
A patient was discharged from the same-day-surgery unit with the following diagnoses:
posterior subcapsular, mature, incipient, senile cataract right eye, diabetes mellitus,
hypertension, and was treated for mild acute renal failure. Which codes are correct?
E11.36Type 2 diabetes mellitus with diabetic cataract
E11.29Type 2 diabetes mellitus with other diabetic kidney complication
E11.9Type 2 diabetes mellitus without complications
H25.9Unspecified age-related cataract
H25.21Age-related cataract, morgagnian type, right eye
H25.041Posterior subcapsular polar age-related cataract, right eyeI10Essential hypertension
I12.9Hypertensive chronic kidney disease with stage 1 through stage 4, or unspecified
chronic kidney disease
N17.9Acute kidney failure, unspecified
a. H25.21, E11.29, I12.9, N17.9
b. E11.36, H25.041, I10, N17.9
c. H25.9, E11.29, I12.9, N17.9
d. H25.041, E11.9, I12.9 Correct Answer: B
The patient has posterior subcapsular, mature, incipient, senile cataract right eye, diabetes
mellitus, hypertension, acute renal failure. The hypertension and diabetes are not related to
Page 1 of 44
,the renal failure as it is acute and not chronic. Because of this, no combination code is
assigned for hypertension, diabetes and chronic renal failure. However, the diabetes and
cataract are related conditions which are coded using a combination code. The classification
presumes a relationship between diabetes and cataracts (CMS 2020a, Sections I.A.15, 12-13
and I.B.9., 15; AHA Coding Clinic 2016 2nd Quarter, 36-37; AHA Coding Clinic 2019 2nd
Quarter, 30).
145
Correct0
Wrong1
Unanswered45
Current Procedural Terminology (CPT) defines a separate procedure as which of the
following?
a. Procedure considered an integral part of a more major service
b. Provision of anesthesia
c. Procedure that requires an add-on code
d. A surgical procedure performed in conjunction with an E&M visit Correct Answer: A
When a procedure is designated as a separate procedure in the CPT code book and it is
performed in conjunction with another service, it is considered an integral part of the major
service. The CPT code description includes "separate procedure." The intention is not to
provide payment for a procedure that is already integral to any given procedure (Smith 2020,
68-69; AMA CPT Professional Edition 2020, 72-73).
Documentation from the nursing or other allied health professionals' notes can be used to
provide specificity for code assignment for which of the following diagnoses?
Page 2 of 44
,a. Body mass index (BMI)
b. Malnutrition
c. Aspiration pneumonia
d. Fatigue Correct Answer: A
The physician must establish the diagnosis—obesity or morbid obesity—and the additional
information can be pulled from ancillary documentation to establish the correct code
assignment for body mass index (BMI) (CMS 2020a, Section I.B.14, 17-18).
A laparoscopic cholecystectomy was performed. What is the correct ICD-10-PCS code?
0FB40ZZExcision of gallbladder, open approach
0FB44ZZExcision of gallbladder, percutaneous endoscopic approach
0FT40ZZResection of gallbladder, open approach
0FT44ZZResection of gallbladder, percutaneous endoscopic approach
a. 0FB40ZZ
b. 0FT40ZZ
c. 0FT44ZZ
d. 0FB44ZZ Correct Answer: C
A cholecystectomy includes complete removal of the gallbladder; therefore, the correct root
operation is Resection. Since the procedure is specified as a laparoscopic cholecystectomy,
the approach is percutaneous endoscopic (Leon-Chisen 2020, 247-248).
Page 3 of 44
, Carcinoma of multiple overlapping sites of the bladder. Diagnostic cystoscopy and
transurethral fulguration of bladder lesions over the dome and posterior wall (1.9 cm.) was
completed. A biopsy was taken of a lesion in the lateral wall. What modifier should be added
to the biopsy procedure code?
a. -50, Bilateral procedure
b. -51, Multiple procedures
c. -59, Distinct procedural service
d. -99, Multiple modifiers Correct Answer: C
The surgery is done on two distinct areas within the bladder with two distinct approaches.
The biopsy is not of the area that was resected and warrants the use of -59 (CPT Assistant
Sept. 2001; CPT Professional Edition 2020, Appendix A).
A bronchoscopy with multiple biopsies of the left bronchus was completed and revealed
adenocarcinoma. What, if any, modifier should be added to the procedure code billed by the
facility?
a. -59, Distinct procedural service
b. -51, Multiple procedures
c. -76, Repeat procedure or service by same physician
d. No modifiers should be reported Correct Answer: D
The procedure is reported with code 31625, the description of which indicates biopsy of
single or multiple sites. When reporting this code, it is not necessary to indicate multiple
procedures as the code itself does that (AMA CPT Professional Edition 2020, Appendix A).
Page 4 of 44
