Certified Coding Specialist (CCS) Exam Questions and Answers, Exams of Nursing

Download Certified Coding Specialist (CCS) Exam Questions and Answers and more Exams Nursing in PDF only on Docsity! 1 [Date] 1 Certified Coding Specialist (CCS) Exam Questions and answer latest updated 2023 1. Carcinoma in situ - ✅✅✅Tumor cells that are undergoing malignant changes but are still confined to the point of origin without invasion of the surrounding normal tissue 2. Examples of carcinoma in situ - ✅✅✅Intraepithelial infiltrating 3. The patient was admitted from the emergency department because of chest pain. Following blood work, it was determined that the patient had elevated CPKs and MB enzymes. The EKG shows nonspecific ST changes. 4. What type of diagnosis might this indicate? a. Unstable angina b. Myocardial infarction c. Congestive heart failure d. Mitral valve stenosis - ✅✅✅b 5. The CPK elevation with MB enzymes elevated and the EKG ST changes denote a possible Ml (Leon-Chisen 2013, 386-387). 6. A patient is admitted and diagnosed with fever and urinary burning. The discharge diagnosis· is Escherichia coli, urinary tract infection. 7. Which of the following represents the correct diagnoses and appropriate sequence of those conditions? a. Fever, urinary burning, urosepsis b. Fever, urinary burning, sepsis c. Escherichia coli, urinary tract infection d. Urinary tract infection, Escherichia coli - ✅✅✅d 8. Symptoms are not coded when a definitive diagnosis is present on discharge. The patient discharge diagnosis of urinary tract infection. The organism (E. coli) is coded with a seco diagnosis code (B96.20) which is to be added as an additional code to identify the bacterial agent (HHS 2014, Section II.A., 98). 2 [Date] 1 9. A patient was admitted with heart failure within one week of a heart transplant. Due to the timing, the coder thought that it may represent a postoperative transplant rejection following heart transplant. 10. What action(s) should the coding staff take? a. Query the physician. b. Assign the codes for the postoperative transplant rejection. c. Assign only the code for the transplant rejection. d. Assign only the code for heart failure. - ✅✅✅a 11. When the documentation is not clear regarding a potential complication, it is appropriate query the physician (HHS 2014, Section I.B.16, 16; Leon-Chisen 2013, 43- 44). 12. A patient is admitted to a psychiatric unit of an acute-care facility. The patient experienced the following symptoms almost every day for the last month: loss of interest or pleasure in most or all activities, which is a change from her prior level of functioning. She has also gained 15 lbs, has difficulty falling asleep, feels fatigued, and has difficulty making decisions. 13. What potential diagnosis most closely fits the patient's overall symptoms? a. Insomnia b. Major depression c. Reye's syndrome d. Bipolar disorder - ✅✅✅b 14. The symptoms provided are indicative of a depressive disorder (Leon-Chisen 2013, 175). 15. Inpatient: 16. Admission for inguinal hernia repair. This 30-year-old patient has acquired immunodeficiency syndrome (AIDS) but is not symptomatic at this time due to medication regimen. The procedure performed was a right indirect inguinal herniorrhaphy via open approach. - ✅✅✅ICD-10-CM: K40.90, B20, 5 [Date] 1 39. Inpatient: 40. A 77-year-old nursing home patient was admitted to the acute care setting for excisional debridement of decubitus stage 3 ulcer of the right heel via surgical excision in the OR. The patient also has degenerative joint disease of both knees. - ✅✅✅ICD-10-CM: L89.613, M17.0, 41. ICD-10-PCS: OJBQOZZ 42. (Schraffenberger 2013, 265-266, 278, 282-284). 43. Inpatient: 44. 45-year-old woman was admitted to the inpatient setting for a displacement of a lumbar intervertebral disk. This was treated with a laminectomy and diskectomy. - ✅✅✅ICD-10- CM: M51.26, 45. ICD-10-PCS: OSB20ZZ, OQBOOZZ 46. (Schraffenberger 2013,279, 282-284). 47. Inpatient: 48. A 34-year-old woman delivered a live born, term baby boy (39 weeks) with macrosomia. She had a hemorrhage following an episiotomy with a low forceps delivery but prior to expulsion of the placenta. - ✅✅✅ICD-10-CM: 067.9, 033.7, Z37.0, Z3A.39, ICD-10-PCS: 10D07Z3, OW8NXZZ- 49. The patient had a hemorrhage that occurred after delivery but before the expulsion of the placenta. This hemorrhage, by definition, occurred in the third stage of labor (Schraffenberger 2013, 270, 278-283, 313). 6 [Date] 1 50. Inpatient: 51. A single, newborn, term live-born baby boy, born in hospital via vaginal delivery. - ✅✅✅ICD-10-CM: Z38.00 52. (Schraffenberger 2013, 340). 53. Inpatient: 54. Twin newborns, both born prematurely at 32 weeks via cesarean section, 1,002 g was the birth weight of the first twin, whose mate was stillborn. The baby was admitted to the nursery from the delivery room. The baby also was treated for jaundice due to ABO incompatibility. - ✅✅✅ICD-10-CM: Z38.31, P07.14, P07.35, P55.1 55. (Schraffenberger 2013, 337). 56. Inpatient: 57. A patient is admitted to the acute care facility with chest pain. The patient was awakened from sleep; this was ;:he patient's first experience with chest pain. The patient was given two nitroglycerin tablets in the emergency department. The chest pain was not relieved, resulting in the diagnosis of new onset unstable angina. Serial CPK was normal. Following a left cardiac catheterization with angiogram of multiple coronary arteries with low osmolar contrast, the patient is found to have arteriosclerotic coronary artery disease. - ✅✅✅ICD-10-CM: 125.110, 58. ICD-10-PCS: 4A023N7, B2111ZZ 59. (Schraffenberger 2013, 202-204). 7 [Date] 1 60. Inpatient: 61. This is the first admission for a patient with adenocarcinoma of the right lower lung who was also found with metastasis to the brain. The patient underwent a right lower lung lobectomy via laparotomy. - ✅✅✅ICD-10-CM: C34.31, C79.31, 62. ICD-10-PCS: OBTFOZZ 63. (Schraffenberger 2013, Chapter 5, 99). 64. Inpatient: 65. A patient has metastatic adenocarcinoma of bone. - ✅✅✅ICD-10-CM: C80.1, C79.51 66. (Schraffenberger 2013, 99). 67. Inpatient: 68. A patient is admitted with metastatic carcinoma from breast to liver with previous bilateral mastectomy and no reoccurrence at the primary site. - ✅✅✅ICD-10-CM: C78.7, Z85.3, Z90.13 69. (Schraffenberger 2013, 478). 70. Inpatient: 71. A young woman was admitted after a car hit her from behind while she waited for a bus on the sidewalk. She sustained a fractured fibula shaft and patella on the left leg with a break in the skin at the midcalf. The patient 10 [Date] 1 95. (Schraffenberger 2013, 99-100; CPT Assistant Fa11199-. _ May 1996, 11; Feb. 2008, 8; Feb. 2010, 3; CPT Changes: An Insider's View 2003). 96. Ambulatory/Outpatient 97. Hallux valgus repair with resection of the joint with implant in the first left toe proximal phalanx. - ✅✅✅CD-10-CM: M20.12; 98. CPT: 28293-TA 99. (Schraffenberger 2013, 305; CPT Assistant Dec. 1996. 6; CPT Assistant Jan. 2007, 31). 100. Ambulatory/Outpatient 101. Metastatic ovarian cancer to the pleura. Thoracoscopic pleurodesis. - ✅✅✅ICD-10- CM: C78.2, C56.9; 102. CPT: 32650 103. (Schraffenberger 2013, 100-101; CPT Assistant F 1994, 1, 6; CPT Changes: An Insider's View 2002). 104. Ambulatory/Outpatient 105. Symptomatic bradycardia due to sick sinus syndrome with replacement of dual chamber pacemaker generator with removal of old generator. - ✅✅✅ICD-10-CM: 149.5; CPT: 33228 (Schraffenberger 2013, 206, 362-363; CPT Changes: An In-sider's View 2003; CPT Assistant Summer 1994, 10, 19; CPT Assistant Nov. 1999, 16; CPT CHANGES 200,2013 106. Ambulatory/Outpatient 107. Esophagogastroduodenoscopy with sclerotherapy of esophageal varices. - ✅✅✅ICD-10-CM: 185.00; 11 [Date] 1 108. CPT: 43243 109. Leon-Chisen 2013, 246; Smith 2015, 115; CPT assistant Spring 1994, 4). 110. Ambulatory/Outpatient 111. Transurethral resection of the prostate for benign prostatic hypertrophy with electrocautery. - ✅✅✅ICD-10-CM: N40.0; 112. CPT: 52601 ( 113. Schraffenberger 2013, 294-295; Smith 2015, 134; CPT Assistant Nov. 1997, 20; CPT Assistant April2001, 4; CPT Assistant June 2003, 6). 114. Ambulatory/Outpatient 115. Cryosurgical destruction of simple papilloma of the penis. - ✅✅✅ICD-10-CM: D29.0; 116. CPT: 54056 117. (Schraffenberger 2013, 103; Smith 2015, 134). 118. Ambulatory/Outpatient 119. Dysfunctional uterine bleeding for which hysteroscopy with endometrial ablation was undertaken. - ✅✅✅CD-10-CM: N93.8; 120. CPT: 58563 121. (Schraffenberger 2013, 296; CPT Assistant Nov. 1999,2 : March 2000, 10; March 2002, 11; CPT Changes: An Insider's View 2000, 2002). 12 [Date] 1 122. Ambulatory/Outpatient 123. Incompetent cervix in second trimester with removal of cervical cerclage under spinal anesthesia in a pregnant woman. - ✅✅✅ICD-10-CM: 034.32; 124. CPT: 59871 125. (Leon-Chisen 2013, 343; CPT Assistant Nov. 1997, 2 CPT Assistant Nov. 2006, 21; CPT Assistant Feb. 2007, 10) 126. A patient is admitted to the hospital complaining of abdominal pain. Following evaluation, it was determined that the patient had an intestinal obstruction of the left colon due to adhesions from a prior abdominal surgery. The patient underwent an exploratory laparotomy with lysis of adhesions. 127. What conditions should be coded? a. Abdominal pain, abdominal adhesions, abdominal obstruction, laparotomy, lysis of adhesions b. Abdominal adhesions, abdominal obstruction, postoperative complications of the digestive system, laparotomy, lysis of adhesions c. Abdominal adhesions with obstruction, lysis of adhesions d. Abdominal adhesions and abdominal obstruction, postoperative complications of the digestive system, lysis of adhesions - ✅✅✅c 128. The patient has abdominal adhesions with obstruction, and lysis of adhesions was performed. The abdominal pain is not coded as it is a symptom (HHS 2014, Section I.B.4, 13; Leon-Chisen 2013,140) 15 [Date] 1 136. The care rendered to the patient and the patient's response must be documented in the medical record (LaTour and Eichenwald Maki 2013, 264; Sayles 2013, 70). 137. Authentication of health record entries means to: a. Create facsimiles of documents b. Prove authorship of documents c. Develop documents d. Use a rubber stamp on random sets of documents - ✅✅✅b 138. Authentication is the act of verifying a claim of identity (Sayles 2013, 381). In order to prove authorship of documents they are required to be authenticated by a signature (LaTour and Eichenwald Maki 2013, 264). 139. The requirements for documentation and record completion (documents such as history and physicals, discharge summaries, and consultations) as well as penalties for non-adherence must be specified in: a. Hospital rules and regulations b. Conditions of nonparticipation c. Medical staff bylaws d. Nursing staff policies - ✅✅✅c 16 [Date] 1 140. The medical staff bylaws are required by accreditation and regulatory organizations to refer to the timeline required for completion (LaTour and Eichenwald Maki 2013, 240; Sayles 2014, 353). 141. A patient was admitted to the emergency department for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease. 142. List the diagnoses that would be coded in the order of sequence. a. Abdominal pain, infectious gastroenteritis, chronic obstructive pulmonary disease, angina b. Infectious gastroenteritis, chronic obstructive pulmonary disease, angina c. Gastroenteritis, abdominal pain, angina d. Diarrhea, chronic obstructive pulmonary disease, angina - ✅✅✅b 143. The abdominal pain and diarrhea are not coded as they are symptoms integral to the diagnosis of infectious gastroenteritis. Review Coding Guideline II.A, 98 for additional information on coding of symptoms, signs, and ill-defined conditions. 144. A patient was admitted to the endoscopy unit for a screening colonoscopy. During the colonoscopy, polyps of the colon were found and a polypectomy was performed. 145. What diagnostic codes should be used and how should they be sequenced? 17 [Date] 1 146. Z12.11 Encounter for screening for malignant neoplasm of colon 147. D12.6 Benign neoplasm of colon, unspecified a. Z12.11 b. Dl2.6 Encounter for screening for malignant neoplasm of colon Benign neoplasm of colon, unspecified c. Zl2.ll,Dl2.6 d. D12.6, Z12.11 - ✅✅✅c 148. The circumstances of the encounter are for a screening colonoscopy. Because of this the screening, colonoscopy is listed first, followed by a code for the polyps (HHS 2014, Section I.C.21.c.5, 88). 149. 023-Other benign neoplasms of skin Includes: Benign neoplasm of hair follicles Benign neoplasm of sebaceous glands Benign neoplasm of sweat glands Excludes 1: benign lipomatous neoplasms of skin (017.0-017.3) melanocytic nevi (022.-) 150. When coding benign neoplasm of the skin, the section noted above directs the coder to: a. Use category D23 for benign neoplasm of sweat glands b. Use category D23 for melanocytic nevi