CCA Certified Coding Associate CCA Exam
Question 1. Which coding classification system is primarily used for reporting diagnoses in inpatient
hospital settings in the United States?
A) CPT
B) HCPCS Level II
C) ICD-10-CM
D) SNOMED CT
Answer: C
Explanation: ICD-10-CM is the system used for coding diagnoses in all healthcare settings, including
inpatient hospital settings in the U.S.
Question 2. What is the primary purpose of CPT codes?
A) To classify diseases
B) To report procedures and services provided by physicians
C) To describe durable medical equipment
D) To code for laboratory tests only
Answer: B
Explanation: CPT codes are used to report medical, surgical, and diagnostic procedures and services
performed by healthcare providers.
Question 3. When abstracting a medical record, which section typically contains the patient’s allergies?
A) History and Physical
B) Progress Notes
C) Medication Administration Record
D) Admission Face Sheet
Answer: A
Explanation: Allergies are usually documented in the History and Physical section, as they are critical for
safe patient care.
Question 4. In ICD-10-CM, what is the correct coding convention if a condition is documented as
“probable” or “suspected” in an inpatient record?
A) Code the diagnosis as if it existed or was established
B) Do not code the diagnosis
C) Query the physician
D) Use a symptom code only
Answer: A
Explanation: For inpatient settings, uncertain diagnoses are coded as if they exist, per ICD-10-CM
guidelines.
Question 5. Which of the following is an example of a valid principal diagnosis?
A) Status post cholecystectomy
B) Chest pain
C) Pneumonia
D) Rule out myocardial infarction
Answer: C
Explanation: Pneumonia is an actual condition, whereas “rule out” or status post surgery are not valid
principal diagnoses.
