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Certified Coding Specialist (CCS) Practice Exam: ICD-10 & CPT Coding, Exams of Advanced Education

American Public University System (APUS)Advanced Education

A series of multiple-choice questions related to medical coding, specifically focusing on icd-10-cm and cpt coding guidelines. It covers various scenarios involving diagnoses, procedures, and coding principles relevant to hospital settings. The questions test the coder's ability to apply coding guidelines, select appropriate codes, and understand coding conventions. It is useful for students and professionals in medical coding, providing practical examples and challenging coding scenarios to enhance their skills and knowledge in medical coding practices. Questions about coding burns, fractures, and other medical conditions.

Typology: Exams

2024/2025

Available from 07/13/2025

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Certified Coding Specialist Practice
Exam-Graded A
Aidan is a 3 yr. old male who swallowed Drano crystals. He presents to the ED with
vomiting and decreased level of consciousness. He is examined by Dr. Harris whose
final diagnoses include second degree burns of mouth and throat, vomiting and altered
level of consciousness secondary to ingestion of Drano. Aidan's diagnoses are coded
as _________________. - ANSWER-A corrosion and a toxic effect
Which of the following diagnoses is considered an MCC? - ANSWER-Cerebral
infarction due to unspecified occlusion or stenosis of unspecified carotid artery
Lana comes to the endoscopy suite for a colonoscopy secondary to bleeding from
rectum. A suspicious lesion is found in the sigmoid colon and biopsied. The post op
diagnosis on the endoscopy report is "Lesion of large intestine, rule carcinoma". The
pathological analysis of the biopsy specimen identifies the lesion as ulcerative colitis.
Which of the following conditions would be coded as the primary diagnosis for Lana's
colonoscopy? - ANSWER-Ulcerative colitis
Kameron has oropharyngeal phase dysphagia secondary to a previous cerebrovascular
accident which has resulted in him becoming dehydrated. He is admitted to ABC
Hospital for rehydration. What is the correct ICD-10-CM code assignment for this
admission? - ANSWER-E86.0, I69.391, R13.12
Sherman had posterior spinal fusion of L3-L5 performed via posterior approach. Fusion
was an interspace. What is the correct CPT code assignment and sequencing for this
procedure? - ANSWER-22612, 22614, 22853, 22853, 20930
Marshall, who is terminally ill and has been under hospice care at home is transferred to
ABC Hospital for palliative care. Based on the table, what point of origin code will be
assigned for Marshall's admission to the hospital? - ANSWER-F
Penny has stones in her left kidney with accompanying hydronephrosis. Dr. Qadir treats
Penny with lithotripsy via left ureteroscopy. Once the stones are fragmented. Dr. Qadir
removes the fragments with a stone basket and inserts a double J stent in the left
ureter. What is the correct CPT code assignment for this procedure? - ANSWER-52352-
LT, 52356-LT
Which of the following diagnoses is not considered a CC or MCC? - ANSWER-
Coalworker's pneumoconiosis (black lung disease)
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Certified Coding Specialist Practice

Exam-Graded A

Aidan is a 3 yr. old male who swallowed Drano crystals. He presents to the ED with vomiting and decreased level of consciousness. He is examined by Dr. Harris whose final diagnoses include second degree burns of mouth and throat, vomiting and altered level of consciousness secondary to ingestion of Drano. Aidan's diagnoses are coded as _________________. - ANSWER-A corrosion and a toxic effect Which of the following diagnoses is considered an MCC? - ANSWER-Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid artery Lana comes to the endoscopy suite for a colonoscopy secondary to bleeding from rectum. A suspicious lesion is found in the sigmoid colon and biopsied. The post op diagnosis on the endoscopy report is "Lesion of large intestine, rule carcinoma". The pathological analysis of the biopsy specimen identifies the lesion as ulcerative colitis. Which of the following conditions would be coded as the primary diagnosis for Lana's colonoscopy? - ANSWER-Ulcerative colitis Kameron has oropharyngeal phase dysphagia secondary to a previous cerebrovascular accident which has resulted in him becoming dehydrated. He is admitted to ABC Hospital for rehydration. What is the correct ICD-10-CM code assignment for this admission? - ANSWER-E86.0, I69.391, R13. Sherman had posterior spinal fusion of L3-L5 performed via posterior approach. Fusion was an interspace. What is the correct CPT code assignment and sequencing for this procedure? - ANSWER-22612, 22614, 22853, 22853, 20930 Marshall, who is terminally ill and has been under hospice care at home is transferred to ABC Hospital for palliative care. Based on the table, what point of origin code will be assigned for Marshall's admission to the hospital? - ANSWER-F Penny has stones in her left kidney with accompanying hydronephrosis. Dr. Qadir treats Penny with lithotripsy via left ureteroscopy. Once the stones are fragmented. Dr. Qadir removes the fragments with a stone basket and inserts a double J stent in the left ureter. What is the correct CPT code assignment for this procedure? - ANSWER-52352- LT, 52356-LT Which of the following diagnoses is not considered a CC or MCC? - ANSWER- Coalworker's pneumoconiosis (black lung disease)

Which of the following are always considered exempt from present on admission reporting? - ANSWER-Congenital conditions Candace suffered a laceration on her eft leg when she fell from her bicycle into gravel that contained broken glass. Her mother took her to ABC Hospital's instant care where Dr. Galu removed gravel and glass from the wound, irrigated the wound extensively with antibiotic solution and then repaired the laceration by single-layer suture of the dermis and epidermis. Based on CPT Integumentary System guidelines for "Repair" which of the following should be reported for treatment of Cadence's laceration? - ANSWER- Intermediate repair Anthony is coding a lumbar epidural steroid injection performed under uroscopy. When he enters his codes, the encoder gives him the following information. Based on the information from the encoder which of the following is the correct coding for this procedure? - ANSWER- Which of the following is true about selection the principal ICD-10-PCS procedure code? - ANSWER-The principal ICD-10-PCS procedure code is the one most closely related to the principal diagnosis Samuel is admitted to the hospital with chest pain and shortness of breath. After extensive work-up the attending physician's final diagnostic statement is: Chest pain and shortness of breath; suspect congestive heart failure or ischemic cardiomyopathy. If all work-up and treatment for the suspected conditions are equal, what is the appropriate coding action? - ANSWER-Sequence as the prinicipal the diagnosis that optimizes the relative weight of the MS-DRG Which of the following cholelithiasis/cholecystitis diagnoses is considered a CC? - ANSWER-K81. The modifier is appended to the code for the second instance of a procedure when the same procedure is repeated by the same physician on the date of service. - ANSWER- Modifier 76 Harriet is serving a 90 day sentence in the county jail. During this time, she develops acute appendicitis and is taken to ABC Hospital where an appendectomy is performed in the outpatient surgery department. Based on the, what point of origin code will be assigned for Harriet's visit to the hospital? - ANSWER- Carol had left total mastectomy secondary to carcinoma. In light of her previous breast cancer she has elected to have a skin sparing mastectomy of the right breast with concurrent insertion of saline breast implant. In addition, Dr. Telford removed the right axillary sentinel node for biopsy. What is the correct ICD-10-PCS code assignment for this procedure? - ANSWER-0HTT0ZZ, 07B50ZX, OHRT0JZ

Present on Admission indictors play a role in the determination of ____________________________________. - ANSWER-Hospital acquired conditions (HACs) Cassidy is coding Mrs. Danielson for treatment of a burn. The history and physical in the health record include a past medical history of hypertension, but this diagnosis is not included in the final diagnostic statement. Where can Cassidy look for documentation to support assignment of a code for hypertension? - ANSWER-Medication history Which of the following phrases, when found in health record documentations, does not indicate a cause and effect relationship? - ANSWER-In the context of The patient is a 56 yr. old female whose diagnoses include balanitis. Which documentation element is in discrepancy in this scenario? - ANSWER-Gender When coding for poisonings, adverse effects, toxic effects or underdosing, which of the following are default designations? - ANSWER-Adverse effect and accidental Gus is hit by a car and is seen by Dr. Spencer in the ED for an open fracture of the left tibia. To code this diagnosis to the highest degree of severity the coder should review the documentation for which clinical numeric value? - ANSWER-Gustillo classification score Carmela is coding for Mr. Gregorio's inpatient admission. The only diagnosis listed for the visit is ongoing left sided weakness. Mr. Gregorio's past medical history documents a previous cerebral infarction. What is the appropriate coding step for Carmela to take?

  • ANSWER-Query the attending physician about a link between the loft sided weakness and the previous cerebral infarction Mario was admitted to the hospital for a total hip replacement. The operative report noted blood loss of 1000 ml. Post-op day 1, Mario developed difficulty breathing and his hemoglobin showed a drop from 14.2 g/dL to 12.6 g/dL. He was transfused with 1 unit of packed red blood cells. His discharge diagnoses included OA R hip, CKD stage 3, anemia and hypertension. All chronic conditions were treated during the admission. What is the query opportunity for this documentation? - ANSWER-Can the type of anemia be further specified? Trina is a 64 yr. old female patient who was admitted with chest pain and dyspnea after falling into a polluted river. His chest x-ray shows free fluid on the basal segments of both lungs and analysis of her sputum notes the presence of petroleum products. The pulmonology consultation lists a diagnosis of aspiration pneumonia. The discharge diagnosis on the attending physician's discharge summary states only, pneumonia. Which of the following is a complaint query based on this documentation? - ANSWER- Your discharge summary documents a diagnosis of pneumonia. Based on the clinical indicators presented, can the etiology of the patient's pneumonia be further specified as aspiration pneumonia?

Bart is a 56 yr. old male known dysphagia and witnessed aspiration. He develops cough, chest discomfort and fever and is admitted for evaluation. His final diagnosis is "pneumonia". Which of the following is an appropriate non-leading query based on these clinical indicators? - ANSWER-Your discharge summary documents a diagnosis of pneumonia. Based on the clinical factors presented, can the etiology of the patient's pneumonia be further specified? Minerva was admitted to ABC Hospital for difficulty breathing and edema in her legs. Her comorbid conditions included hypertension, diabetes, chronic renal failure, hyperlipidemia and a stage 3 pressure ulcer of the right buttock. During her stay she had an echocardiogram that indicated congestive heart failure with preserved ejection fraction. All of her chronic conditions were treated and she had debridement of her pressure ulcer down to the muscle. Her discharge diagnoses were listed as: congestive heart failure, hypertension, diabetes, chronic renal failure stage II, hyperlipidemia, stage 3 pressure ulcer of right buttock status post debridement. What is the query opportunity for this admission? - ANSWER-The type of debridement A covered entity may deny a patient's request to ______________________________________________________. - ANSWER- Restrict uses and disclosures of their PHI ________________________ conditions that could reasonably have been prevented through the application of evidence-based guidelines. - ANSWER-Hospital acquired conditions (HACs) Earl is coding a record for a patient who had laparoscopic gastric bypass surgery 4 days ago and was discharged to home. The patient came to the ED because of difficulty breathing and was admitted for pneumonia. The examination documented in his admitting history and physical indicates warmth and redness of his surgical wound. On day 2 of the admission a diagnosis of infection of laparoscopic gastric bypass surgical site is documented in the process notes which of the following are true about this patient's diagnosis of infection of laparoscopic gastric bypass surgical site? - ANSWER- The diagnosis is considered a HAC and will not be allowed to influence the MS-DRG Which of the following is true in regard to standards governing the protection of patient privacy and confidentiality, if federal and state protections are not the same? - ANSWER-The requirement of the stricter of the two applies Which of the following was developed to ensure standardization in the data elements that are collected for hospital inpatient admissions? - ANSWER-Uniform Hospital Discharge Data Set (UHDDS) In addition to diagnosis and procedures, which data elements mandated by the UHDDS may influence MS-DRG assignment? - ANSWER-Sex and discharge disposition

clarification and additional documentation prior to final code assignment in accordance with acceptable healthcare industry practices Which of the following disclosures of PHI relies on informal permission from the patient by asking them to agree or object to disclosure? - ANSWER-Including the patient in the facility directory