Certified Coding Specialist Practice Test

AHIMA-CCS test Format | Course Contents | Course Outline | test Syllabus | test Objectives

Number of Questions on exam:
 97 multiple-choice questions (79 scored/18 pretest)
 8 medical scenarios (6 scored/2 pretest)
Exam Time: 4 hours – no breaks
Domain 1 – Health Information Documentation (8-10%)
Tasks:
1. Interpret health record documentation using knowledge of anatomy, physiology, clinical indicators and disease processes, pharmacology and medical terminology to identify codeable diagnoses and/or procedures
2. Determine when additional clinical documentation is needed to assign the diagnosis and/or procedure code(s)
3. Consult with physicians and other healthcare providersto obtain further clinical documentation to assist with code assignment
4. Compose a compliant physician query
5. Consult reference materialsto facilitate code assignment
6. Identify patient encounter type
7. Identify and post chargesfor healthcare services based on documentation

Domain 2 – Diagnosis & Procedure Coding (64-68%)
Tasks:
Diagnosis:
1. Select the diagnosesthat require coding according to current coding and reporting requirementsfor acute care (inpatient) services
2. Select the diagnosesthat require coding according to current coding and reporting requirementsfor outpatient services
3. Interpret conventions, formats, instructional notations, tables, and definitions of the classification system to select diagnoses, conditions, problems, or other reasonsfor the encounter that require coding
4. Sequence diagnoses and other reasons for encounter according to notations and conventions of the classification system and standard data set definitions(such as Uniform Hospital Discharge Data Set [UHDDS])
5. Apply the official ICD-10-CM coding guidelines
Procedure:
1. Select the proceduresthat require coding according to current coding and reporting requirementsfor acute care (inpatient) services
2. Select the proceduresthat require coding according to current coding and reporting requirementsfor outpatient services
3. Interpret conventions, formats, instructional notations, and definitions of the classification system and/ornomenclature to select procedures/servicesthat require coding
4. Sequence procedures according to notations and conventions of the classification system/nomenclature and standard data set definitions(such as UHDDS)
5. Apply the official ICD-10-PCS procedure coding guidelines
6. Apply the official CPT/HCPCS Level II coding guidelines

Domain 3 – Regulatory Guidelines and Reporting Requirements for Acute Care (Inpatient) Service (6-8%)
Tasks:
1. Select the principal diagnosis, principal procedure, complications, comorbid conditions, other diagnoses and proceduresthat require coding according to UHDDS definitions and Coding Clinic
2. Assign the present on admission (POA) indicators
3. Evaluate the impact of code selection on Diagnosis Related Group (DRG) assignment
4. Verify DRG assignment based on Inpatient Prospective Payment System (IPPS) definitions
5. Assign and/or validate the discharge disposition

DOMAIN 4. Regulatory Guidelines and Reporting Requirements for Outpatient Services (6-8%)
Tasks:
1. Select the reason for encounter, pertinentsecondary conditions, primary procedure, and other proceduresthat require coding according to UHDDS definitions, CPT Assistant, Coding Clinic, and HCPCS
2. Apply Outpatient Prospective Payment System (OPPS) reporting requirements:
a. Modifiers
b. CPT/ HCPCS Level II
c. Medical necessity
d. Evaluation and Management code assignment (facility reporting)
3. Apply clinical laboratory service requirements

DOMAIN 5. Data Quality and Management (2-4%)
Tasks:
1. Assess the quality of coded data
2. Communicate with healthcare providersregarding reimbursementmethodologies, documentation rules, and regulationsrelated to coding
3. Analyze health record documentation for quality and completeness of coding
4. Review the accuracy of abstracted data elementsfor database integrity and claims processing
5. Review and resolve coding edits such as Correct Coding Initiative (CCI), Medicare Code
Editor (MCE) and Outpatient Code Editor (OCE)

DOMAIN 6. Information and Communication Technologies (1-3%)
Tasks:
1. Use computer to ensure data collection,storage, analysis, and reporting of information.
2. Use common software applications(for example, word processing,spreadsheets, and email) in the execution of work processes
3. Use specialized software in the completion of HIM processes

DOMAIN 7. Privacy, Confidentiality, Legal, and Ethical Issues (2-4%)
Tasks:
1. Apply policies and proceduresfor access and disclosure of personal health information
2. Apply AHIMA Code of Ethics/Standards of Ethical Coding
3. Recognize and report privacy and/or security concerns
4. Protect data integrity and validity using software or hardware technology

DOMAIN 8. Compliance (2-4%)
Tasks:
1. Evaluate the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards
2. Monitor compliance with organization-wide health record documentation and coding guidelines
3. Recognize and report compliance concerns

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Medical
AHIMA-CCS
Certified Coding Specialist (ICD-10-CM / ICD-10-PCS
/ CPT)
https://killexams.com/pass4sure/exam-detail/AHIMA-CCS
Question: 562
Which ICD-10-CM code is used to report a patient's personal history of breast cancer?
86.11
87.891
90.11
wer: A
anation: The correct ICD-10-CM code to report a patient's personal hi east cancer is Z85.3. This code is used to indicate a personal history o gnant neoplasm, and the additional characters can be used to specify t
nd location of the cancer.
stion: 563
ission Date: 4/24 harge Date: N/A
itting Diagnosis: Non-ST elevation myocardial infarction (NSTEMI) Complaint: A 62-year-old male presented to the emergency departm hest discomfort, diaphoresis, and shortness of breath.
Z85.3
Z
Z
Z
Ans
Expl story
of br f
mali he
type a
Que
Adm Disc Adm
Chief ent
with c
Past Medical History: Hypertension, hyperlipidemia, diabetes mellitus Physical Exam:
General: Diaphoretic, in distress
Cardiovascular: Irregular heart rhythm, elevated cardiac enzymes Impression: The patient was diagnosed with non-ST elevation myocardial infarction based on the clinical presentation, electrocardiogram findings, and elevated cardiac enzyme levels.
Plan: The patient was admitted to the cardiac care unit for further management, including antiplatelet therapy and cardiac catheterization.
What should the principal ICD-10-CM code be for this encounter? A. I21.4
1. I21.9
21.1
1.2
1.3
21.9 and I50.9
wer: A
anation: The principal ICD-10-CM code for this encounter should be The patient presented with symptoms and was diagnosed with non- ation myocardial infarction (NSTEMI). The I21.4 code represents non ation (NSTEMI) myocardial infarction, which accurately describes the
ition in this scenario. The clinical presentation, electrocardiogram fin levated cardiac enzyme levels support the selection of this code. tional codes for hypertension (I10), hyperlipidemia (E78.5), and diabe tus (E11.9) may also be assigned as secondary diagnoses if document upported by the medical record.
stion: 564
I21.0
2. I
3. I2
4. I2
5. I
Ans Expl
I21.4. ST
elev -ST
elev
cond dings,
and e
Addi tes
melli ed
and s
Que
A patient with a history of diabetes mellitus type 2 presents for a routine follow-up visit. During the visit, the physician performs a comprehensive examination and adjusts the patient's medication. Which CPT code should be reported for this encounter?
A. 99212
B. 99213
C. 99214
D. 99215
Answer: C
opriate when the physician performs a detailed history, detailed mination, and moderate complexity medical decision-making.
stion: 565
tient undergoes a left total mastectomy with axillary lymph node diss reast cancer. Which CPT code should be assigned for this procedure?
9303
9304
9305
9307
wer: C
anation: The correct CPT code for a left total mastectomy with axillar h node dissection is 19305. This code is used when the entire breast t moved, along with lymph node dissection.
Explanation: The correct CPT code to report for a routine follow-up visit with a comprehensive examination and medication adjustment is 99214. This code is appr
exa
Que
A pa ection
for b
1. 1
2. 1
3. 1
4. 1
Ans
Expl y
lymp issue
is re
Question: 566
A patient undergoes a colonoscopy with removal of a small polyp in the sigmoid colon. The polyp is sent for biopsy, which confirms it to be a benign adenomatous polyp. Which CPT code(s) would be reported?
A. 45385
B. 45380
C. 45381
D. 45384, 88305
Answer: A
5 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other n(s) by snare technique)
5 (Surgical pathology, gross and microscopic examination for tumor, p, or other lesion [except for Mohs surgery]; single specimen)
is case, the patient undergoes a colonoscopy with removal of a small p sigmoid colon, and the polyp is sent for biopsy. The biopsy confirm to be benign. Therefore, option A is the correct answer, as it include
opriate CPT code for the colonoscopy with removal of the polyp.
stion: 567
ch of the following ICD-10-CM codes is used to report a deep vein mbosis (DVT) of the right lower extremity?
82.421
2.422
2.431
82.432
Explanation: The correct CPT code(s) for this scenario are: 4538
lesio 8830
poly
In th olyp
in the s the
polyp s the
appr
Que
Whi thro
1. I
2. I8
3. I8
4. I
Answer: B
Explanation: The ICD-10-CM code I82.422 is used to report a deep vein thrombosis (DVT) of the right lower extremity. The code I82.422 represents a DVT of the right femoral vein. The specific location and details of the DVT are important factors in selecting the correct code.
Question: 568
A patient presents to the dermatologist for the removal of multiple skin tags on the neck. The physician performs the removal using electrosurgery. Which CPT code should be reported for this procedure?
1200
1201
1202
1204
wer: C
anation: The correct CPT code to report for the removal of multiple s sing electrosurgery is 11202. This code is appropriate when the phys ves 2 to 14 skin tags.
stion: 569
tient is admitted to the hospital with a diagnosis of pneumonia due to ptococcus pneumoniae. Which ICD-10-CM code represents the appro nosis for this patient?
13.0
1
1
1
1
Ans
Expl kin
tags u ician
remo
Que
A pa
Stre priate
diag
1. J
2. J13.1 C. J13.2 D. J13.3
Answer: A
Explanation: The correct answer is A (J13.0). The appropriate ICD-10-CM
code for pneumonia due to Streptococcus pneumoniae is determined by the specific type of pneumonia. In this case, "J13.0" represents the correct code, which specifically indicates "Pneumonia due to Streptococcus pneumoniae."
Question: 570
xternal cause codes are required for all healthcare encounters
xternal cause codes are used to indicate the intent of an injury or pois xternal cause codes are only used for inpatient encounters
xternal cause codes are found in Chapter 20 of ICD-10-CM wer: B
anation: External cause codes in ICD-10-CM are used to provide ional information about the cause, intent, and circumstances of an inj oning, or other external events. They are not required for all healthcar unters, but they may be used when documenting the cause of an injur ntent behind a poisoning. External cause codes can be used for both ient and outpatient encounters and can be found in Chapter 20 of ICD
stion: 571
Which of the following is true regarding the coding of external cause of morbidity in ICD-10-CM?
1. E
2. E oning
3. E
4. E
Ans Expl
addit ury,
pois e
enco y or
the i
inpat -10-
CM.
Que
Which of the following ICD-10-CM codes is used to report a migraine without aura?
A. G43.001 B. G43.009 C. G43.101 D. G43.109
Answer: BExplanation: The ICD-10-CM code G43.009 is used to report a migraine without aura. The code G43.009 represents a migraine without aura, not intractable, without status migrainosus.
60.01
0.02
0.11
60.12
wer: A
anation: The ICD-10-CM code I60.01 is used to report a nontraumati rachnoid hemorrhage. The code I60.01 represents a nontraumatic rachnoid hemorrhage from carotid siphon and bifurcation.
stion: 572
tient undergoes a diagnostic bronchoscopy with bronchoalveolar lava valuation of a lung infection. Which CPT code should be assigned for
Which of the following ICD-10-CM codes is used to report a nontraumatic subarachnoid hemorrhage?
1. I
2. I6
3. I6
4. I
Ans
Expl c
suba suba
Que
A pa ge for
the e this
procedure?
A. 31622
B. 31623
C. 31625
D. 31628
Explanation: The CPT code for a diagnostic bronchoscopy with bronchoalveolar lavage is 31623. This code specifically identifies the performance of a lavage during the bronchoscopy procedure.
Question: 573
ission Date: 2/24 harge Date: N/A
itting Diagnosis: Major depressive disorder, single episode, moderate Complaint: A 40-year-old female presented to the psychiatrist's offi a depressed mood, loss of interest, and feelings of worthlessness.
edical History: None documented ical Exam:
eral: Poor eye contact, psychomotor retardation hiatric: Depressed affect, anhedonia
ession: The patient was diagnosed with major depressive disorder, sin ode, moderate based on the clinical presentation and psychiatric evalu
The patient was prescribed an antidepressant medication and referre hotherapy.
should the principal ICD-10-CM code be for this encounter? 32.1
32.9
Adm Disc Adm
Chief ce
with Past M Phys Gen Psyc
Impr gle
epis ation.
Plan: d for
psyc What
1. F
2. F
3. F32.0 D. F32.2
E. F32.1 and F41.9 F. F32.1 and Z63.0
G. F32.1 and Z87.891 H. F32.1 and Z73.89
der (F41.9) or other relevant diagnoses may also be assigned as secon noses if documented and supported by the medical record.
stion: 574
ch ICD-10-CM code is used to report a patient's personal history of br er in the left breast?
85.3
86.11
87.891
90.11
wer: A
anation: The correct ICD-10-CM code to report a patient's personal hi east cancer in the left breast is Z85.3. This code is used to indicate a onal history of malignant neoplasm, and the additional characters can b
Explanation: The principal ICD-10-CM code for this encounter should be F32.1. The patient presented with symptoms and was diagnosed with major depressive disorder, single episode, moderate. The F32.1 code represents major depressive disorder, single episode, moderate, which accurately describes the condition in this scenario. The clinical presentation and psychiatric evaluation support the selection of this code. Additional codes for generalized anxiety disor dary
diag
Que
Whi east
canc
1. Z
2. Z
3. Z
4. Z
Ans
Expl story
of br
pers e
used to specify the type, location, and laterality of the cancer.
Question: 575
A patient is admitted to the hospital with a diagnosis of acute myocardial infarction (AMI). The physician documents a STEMI (ST-elevation myocardial infarction) of the anterior wall. Which of the following ICD-10-CM codes
A. I21.09 B. I21.01 C. I21.11 D. I21.31
anation: The correct code for a STEMI of the anterior wall is I21.01 ( ation (STEMI) myocardial infarction involving left main coronary arte on A (I21.09) represents other ST elevation (STEMI) myocardial ction, option C (I21.11) represents ST elevation (STEMI) myocardial ction involving left anterior descending coronary artery, and option D
31) represents ST elevation (STEMI) myocardial infarction involving coronary artery of anterior wall.
stion: 576
tient presents to the clinic for a routine mammogram. The mammogra ws a suspicious mass, and a subsequent biopsy confirms a diagnosis of sive ductal carcinoma of the breast. Which ICD-10-CM code should b
ned for the biopsy procedure?
5.11
5.12
Answer: B
Expl ST
elev ry).
Opti infar infar (I21.
other
Que
A pa m
sho
inva e
assig
1. 8
2. 8
C. 85.21
D. 85.22
Answer: B
Explanation: The correct ICD-10-PCS code for a breast biopsy is 85.12. This code specifically identifies the performance of a biopsy procedure on the
Question: 577
Radiology
adiologist, who noted stable findings without any signs of recurrence bnormalities. The radiologist provided a final impression of negative mogram.
CPT code should be reported for the follow-up mammogram? 7065
7066
7067
7068
wer: C
anation: The correct CPT code for the follow-up mammogram is 770 ode represents screening mammography, bilateral (two views of eac st), and is used for routine surveillance or follow-up mammograms. C
5 and 77066 represent diagnostic mammography for unilateral and eral examinations, respectively, and code 77068 represents a diagnosti
Imaging Report: A 55-year-old female patient with a history of breast cancer underwent a follow-up mammogram. The mammogram was performed bilaterally, consisting of two views of each breast. The images were reviewed by a r or
new a mam
What
1. 7
2. 7
3. 7
4. 7
Ans
Expl 67.
This c h
brea odes
7706
bilat c
mammogram performed on a patient with a known breast abnormality. In this case, the mammogram is a routine follow-up, so code 77067 is the appropriate choice.
Question: 578
A patient undergoes a cesarean section delivery for a breech presentation.
A. 59510
B. 59514
C. 59515
D. 59525
anation: The correct CPT code for a cesarean section delivery for a br entation is 59515. This code is used when a cesarean section is perfor nontransverse or oblique lie presentation, such as a breech presentatio
stion: 579
ission Date: 1/24 harge Date: N/A
itting Diagnosis: Acute exacerbation of chronic obstructive pulmonar se (COPD)
Complaint: A 60-year-old male presented to the emergency departm ncreased shortness of breath, wheezing, and coughing up yellowish
um.
edical History: Chronic obstructive pulmonary disease (COPD), king history
ical Exam:
eral: Increased respiratory effort
Answer: C
Expl eech
pres med
for a n.
Que
Adm Disc
Adm y
disea
Chief ent
with i sput Past M smo Phys Gen
Respiratory: Diffuse expiratory wheezes, decreased breath sounds in the bases Impression: The patient was diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD) based on the clinical presentation, physical examination findings, and medical history.
Plan: The patient was admitted to the medical floor for further management, including bronchodilator therapy and oxygen supplementation.
A. J44.0 B. J44.1 C. J44.9
44.0 and J44.9
44.0 and J44.1
wer: A
anation: The principal ICD-10-CM code for this encounter should be
0. The patient presented with symptoms and was diagnosed with an ac erbation of chronic obstructive pulmonary disease (COPD). The J44.0 sents chronic obstructive pulmonary disease with acute lower respirat tion, which accurately describes the condition in this scenario. The cli entation, physical examination findings, and medical history support t tion of this code. Additional codes for tobacco use disorder (F17.210) relevant diagnoses may also be assigned as secondary diagnoses if
mented and supported by the medical record.
stion: 580
ch ICD-10-CM code is used to report a patient's personal history of no
D. J44.0 and F17.210 E. J44.0 and Z87.891 F. J44.0 and Z87.01
1. J
2. J
Ans Expl
J44. ute
exac code
repre ory
infec nical
pres he
selec or
other docu
Que
Whi n-
Hodgkin lymphoma?
A. Z85.79 B. Z86.010 C. Z87.891 D. Z90.11
Explanation: The correct ICD-10-CM code toreport a patient's personal history of non-Hodgkin lymphoma is Z85.79. This code is used to indicate a personal history of other malignant neoplasms of lymphoid, hematopoietic, and related tissues.
stion: 581
ch of the following is an example of unbundling in coding?
eporting multiple services provided during a single patient encounter ombining two or more codes into a single code
oding a symptom instead of a confirmed diagnosis
eparating a procedure into its component parts and coding each part rately
wer: D
anation: Separating a procedure into its component parts and coding e eparately. Unbundling occurs when a procedure is broken down into idual components, and each component is coded and billed separately ad of reporting the procedure as a whole. This practice is considered propriate coding and can result in overpayment. Reporting multiple ces provided during a single patient encounter (A) is not unbundling i
Que
Whi
1. R
2. C
3. C
4. S
sepa Ans
Expl ach
part s its
indiv ,
inste inap
servi f the
services are distinct and separately identifiable. Combining two or more codes into a single code (B) is known as code bundling or code consolidation. Coding a symptom instead of a confirmed diagnosis (C) may be appropriate if a definitive diagnosis has not been established.
A patient is diagnosed with major depressive disorder and is started on pharmacotherapy with an SSRI antidepressant. Which ICD-10-CM code(s) would be reported?
32.0, Z79.891
33.0, Z79.891
wer: A
anation: The correct ICD-10-CM codes for this scenario are: (Major depressive disorder, single episode, unspecified)
891 (Long-term (current) use of selective serotonin reuptake inhibitor RIs])
is case, the patient is diagnosed with major depressive disorder and st harmacotherapy with an SSRI antidepressant. Therefore, option A is t ct answer, as it includes the appropriate ICD-10-CM codes for the nosis and medication.
A. F32.9, Z79.891 B. F33.9, Z79.891
1. F
2. F
Ans Expl
F32.9
Z79. s
[SS
In th arted
on p he
corre diag

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