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CCS (AHIMA) practice questions

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Question 1Coding Knowledge and Skills

In ICD-10-CM, which seventh character is used to indicate the initial encounter for a fracture?

  1. S
  2. D
  3. A Correct answer.
  4. P

Explanation

In ICD-10-CM fracture codes, the seventh character A denotes the initial encounter for the injury. The characters D, G, K, P, and R describe subsequent encounters or sequelae, not the first episode of care.

Question 2Coding Knowledge and Skills

Which modifier indicates a significant, separately identifiable E/M service performed by the same physician on the same day as a procedure?

  1. 59
  2. 57
  3. 24
  4. 25 Correct answer.

Explanation

Modifier 25 is appended to an E/M service when a significant, separately identifiable evaluation and management service is provided by the same physician on the same day as a procedure. Modifier 24 applies to E/M services during a postoperative period for unrelated problems.

Question 3Coding Knowledge and Skills

HCPCS Level II codes are primarily used to report which of the following?

  1. Physician office visits
  2. Inpatient hospital procedures
  3. Clinical laboratory panels
  4. DME and injectable drugs Correct answer.

Explanation

HCPCS Level II is a national code set for items and services not described by CPT, including durable medical equipment, prosthetics, orthotics, and injectable drugs. CPT generally covers professional medical services and procedures.

Question 4Coding Knowledge and Skills

How many characters are in a complete ICD-10-PCS code?

  1. 6
  2. 8
  3. 5
  4. 7 Correct answer.

Explanation

Every ICD-10-PCS code contains exactly seven characters. Each character represents a specific axis of the procedure, such as the body system, root operation, body part, and approach.

Question 5Coding Knowledge and Skills

Which place of service code represents a physician's office?

  1. 21
  2. 11 Correct answer.
  3. 22
  4. 23

Explanation

Place of service code 11 designates services furnished in a physician's office. Code 21 is the inpatient hospital setting, 22 is the outpatient hospital, and 23 is the emergency department.

Question 6Coding Knowledge and Skills

An add-on CPT code is characterized by which of the following?

  1. It is reported only in addition to a primary procedure Correct answer.
  2. It replaces the primary procedure
  3. It may be reported alone when the primary is not performed
  4. It is used only for bilateral procedures

Explanation

Add-on codes describe services that are always performed in addition to a primary procedure and are never reported alone. They are listed in CPT Appendix D and are exempt from multiple procedure reduction.

Question 7Coding Knowledge and Skills

Which ICD-10-CM convention provides separate codes for the right and left sides of paired body parts?

  1. Sequela
  2. Placeholder X
  3. Excludes1
  4. Laterality Correct answer.

Explanation

Laterality is an ICD-10-CM convention that provides distinct codes for the right and left sides of paired body parts. Sequelae, Excludes1, and placeholder X serve other purposes in the classification.

Question 8Coding Knowledge and Skills

Which present on admission (POA) indicator means the condition was present at the time of inpatient admission?

  1. U
  2. W
  3. N
  4. Y Correct answer.

Explanation

The POA indicator Y means the condition was present at the time the patient was admitted to the hospital. N means it was not present, U means documentation is insufficient, and W means the hospital could not determine the status clinically.

Question 9Coding Knowledge and Skills

The principal diagnosis is defined as the condition that, after study, is chiefly responsible for which of the following?

  1. The condition present at the time of discharge
  2. The condition with the longest length of stay
  3. The condition occasioning the admission Correct answer.
  4. The condition requiring the costliest procedure

Explanation

Under the UHDDS definition, the principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission. Length of stay, cost, and discharge status do not determine principal diagnosis.

Question 10Coding Knowledge and Skills

Which service is included in the global surgical package for a procedure with a 90-day global period?

  1. An E/M service for a new problem
  2. Routine postoperative care by the operating physician Correct answer.
  3. A procedure for an unrelated diagnosis during the global period
  4. A return to the operating room for a complication

Explanation

The global surgical package includes routine preoperative, intraoperative, and postoperative care by the operating physician. It does not include services for unrelated problems, and modifier 24 may be used for unrelated E/M services during the global period.

Question 11Coding Knowledge and Skills

A 'code first' instructional note in ICD-10-CM directs the coder to do which of the following?

  1. The underlying condition is sequenced first Correct answer.
  2. The condition is excluded from this chapter
  3. The secondary condition is optional
  4. The code may be reported as principal only

Explanation

A 'code first' note tells the coder to sequence the underlying etiology or cause before the manifestation code. The manifestation code is often accompanied by a 'use additional code' note.

Question 12Coding Knowledge and Skills

An Excludes1 note in ICD-10-CM indicates which of the following?

  1. The note applies only to outpatient claims
  2. The two conditions cannot be coded together Correct answer.
  3. The excluded code may be reported with an additional code
  4. The excluded condition is always coded first

Explanation

An Excludes1 note indicates that the excluded code and the code under the note cannot be reported together because they represent mutually exclusive conditions. Excludes2, by contrast, allows both conditions to be reported when they are unrelated.

Question 13Coding Knowledge and Skills

A 4.5-cm forearm laceration repaired with layered closure involving muscle and fascia is reported as which type of repair?

  1. Simple
  2. Complex Correct answer.
  3. Intermediate
  4. Layered

Explanation

Repair of a laceration involving muscle and fascia, or requiring extensive cleaning or debridement, is classified as complex repair. Simple and intermediate repairs involve superficial or layered closure without extensive involvement of deeper structures.

Question 14Coding Knowledge and Skills

A procedure performed bilaterally on paired organs by the same surgeon during the same session is reported with which modifier?

  1. 50 Correct answer.
  2. 51
  3. LT
  4. RT

Explanation

Modifier 50 reports a procedure performed bilaterally on paired organs or structures during the same operative session by the same surgeon. LT and RT are used when the payer requires separate line items for each side.

Question 15Coding Knowledge and Skills

Anesthesia services are reported using which components?

  1. Base plus time units Correct answer.
  2. Base units alone
  3. Time units alone
  4. Surgical RVUs plus time

Explanation

Anesthesia codes are reported using a base unit value assigned to the procedure plus time units for anesthesia duration. Modifying factors such as physical status may also affect payment.

Question 16Coding Knowledge and Skills

Which modifier identifies a service furnished through synchronous audio-video telehealth?

  1. 95 Correct answer.
  2. 26
  3. 22
  4. 52

Explanation

Modifier 95 identifies a service provided through synchronous, real-time audio-video telehealth technology. It is appended to the appropriate CPT code for the service.

Question 17Coding Knowledge and Skills

In the NCCI edits, a modifier indicator of 0 means which of the following?

  1. Modifier 25 is required
  2. The edit applies only to inpatient claims
  3. The code pair may be billed with modifier 59
  4. No modifier can override the edit Correct answer.

Explanation

NCCI modifier indicator 0 means the edit cannot be overridden with any modifier; the two codes should not be reported together. Indicator 1 means a modifier such as 59 may be used when clinically appropriate.

Question 18Coding Knowledge and Skills

A patient has an open tibial fracture with a 12-cm wound and extensive soft tissue damage. Which seventh character should be assigned for the initial encounter?

  1. A
  2. C Correct answer.
  3. B
  4. D

Explanation

Open fractures are classified by the Gustilo-Anderson type, and ICD-10-CM uses seventh character C for type IIIA, IIIB, or IIIC open fractures. Extensive soft tissue damage and a large wound are consistent with type III.

Question 19Coding Knowledge and Skills

A patient is admitted with sepsis due to E. coli and acute renal failure. Which code set is correct?

  1. A41.9 and N17.9 only
  2. A41.51 and N17.9 without R65.20
  3. N17.9 as principal, A41.51 secondary
  4. A41.51, R65.20, and N17.9 Correct answer.

Explanation

Sepsis due to E. coli is coded A41.51, and organ dysfunction (acute renal failure) makes it severe sepsis, requiring R65.20. The organ dysfunction is then coded additionally with N17.9.

Question 20Coding Knowledge and Skills

During an outpatient visit, the physician documents 'likely pneumonia' but the chest x-ray is negative. Which action is appropriate?

  1. Assign an unspecified pneumonia code
  2. Code only the presenting symptoms
  3. Query the physician first Correct answer.
  4. Code pneumonia as documented

Explanation

Diagnoses documented as 'likely,' 'probable,' or 'rule out' are not coded as confirmed in the outpatient setting; the physician should be queried for clarification. Querying supports accurate code assignment and compliance.

Question 21Coding Knowledge and Skills

When a Medicare service is expected to be denied as not medically necessary, which form should the patient sign before the service is provided?

  1. CMS-1500 claim form
  2. Notice of Privacy Practices form
  3. Assignment of Benefits form
  4. Advance Beneficiary Notice (ABN) Correct answer.

Explanation

An Advance Beneficiary Notice of Noncoverage (ABN) is used when Medicare is expected to deny a service as not medically necessary, allowing the beneficiary to accept financial responsibility. It must be signed before the service is provided.

Question 22Coding Knowledge and Skills

Under the 2021 office/outpatient E/M guidelines, which element determines the level of service?

  1. Number of diagnoses listed
  2. Counselling time only
  3. History and physical examination
  4. MDM or total time Correct answer.

Explanation

Under the 2021 office/outpatient E/M guidelines, the level of service is based on medical decision making or total time on the date of the encounter. History and physical examination elements no longer determine the level for these visits.

Question 23Coding Knowledge and Skills

Which seventh character is assigned when a patient is seen for the late effect of a healed fracture?

  1. S Correct answer.
  2. G
  3. A
  4. D

Explanation

The seventh character S is used for a sequela, which is a late effect of a healed injury or condition. The original injury code is not used for the current encounter.

Question 24Coding Knowledge and Skills

When multiple surgical procedures are performed during the same operative session, which modifier is appended to the secondary procedures?

  1. 62
  2. 50
  3. 22
  4. 51 Correct answer.

Explanation

Modifier 51 is appended to secondary procedures performed during the same operative session to indicate multiple procedures. The primary procedure is reported without modifier 51.

Question 25Coding Knowledge and Skills

Which term describes the surgical removal of the gallbladder?

  1. Choledocholithotomy
  2. Cholecystostomy
  3. Cholecystotomy
  4. Cholecystectomy Correct answer.

Explanation

Cholecystectomy is the surgical removal of the gallbladder. Cholecystotomy is an incision into the gallbladder, choledocholithotomy is removal of a stone from the common bile duct, and cholecystostomy is creation of an opening into the gallbladder.

Question 26Coding Knowledge and Skills

In ICD-10-CM, which character is used as a placeholder to hold a character position when a code requires a seventh character but has fewer than seven characters?

  1. 0
  2. 9
  3. Z
  4. X Correct answer.

Explanation

The placeholder X is used in ICD-10-CM to fill empty character positions so that a required seventh character remains in the seventh position. It does not change the clinical meaning of the code.

Question 27Coding Knowledge and Skills

CPT modifier 26 indicates which of the following?

  1. Bilateral procedure
  2. Technical component
  3. Multiple procedures
  4. Professional component Correct answer.

Explanation

Modifier 26 identifies the professional component of a service that has both professional and technical components. It is commonly used when the physician interprets a diagnostic test but does not own the equipment.

Question 28Coding Knowledge and Skills

Which HCPCS Level II modifier indicates that a service was performed on the left side?

  1. FA
  2. LT Correct answer.
  3. E1
  4. RT

Explanation

The LT modifier is used to indicate that a procedure or service was performed on the left side of the body. It is part of the HCPCS Level II modifier system and may be used with CPT codes.

Question 29Coding Knowledge and Skills

A patient is considered a new patient if they have not received any professional services from the physician or physician group of the same specialty within how many years?

  1. 1 year
  2. 2 years
  3. 5 years
  4. 3 years Correct answer.

Explanation

CPT defines a new patient as one who has not received any professional services from the physician, or another physician of the same specialty in the same group practice, within the past three years. After that period, the patient may be considered new again.

Question 30Coding Knowledge and Skills

In ICD-10-CM, when the word "with" appears in a code title, it means which of the following?

  1. An external cause code is required
  2. The two conditions must be documented as unrelated
  3. Presumed causal relationship unless stated otherwise Correct answer.
  4. The condition must be present on admission

Explanation

The ICD-10-CM convention for "with" states that a causal relationship is presumed unless the documentation clearly indicates the conditions are unrelated. Coders do not need the physician to explicitly link the two conditions in most cases.

Question 31Coding Knowledge and Skills

CPT modifier 59 indicates which of the following?

  1. Surgical care only
  2. Discontinued procedure
  3. Reduced services
  4. Distinct procedural service Correct answer.

Explanation

Modifier 59 is used to indicate that a procedure or service was distinct and independent from other services performed on the same day. It helps explain why a normally bundled service should be reported separately.

Question 32Coding Knowledge and Skills

CPT modifier TC indicates which of the following?

  1. Technical component Correct answer.
  2. Global service
  3. Bilateral procedure
  4. Professional component

Explanation

Modifier TC identifies the technical component of a service, such as the equipment, supplies, and technician work. It is the counterpart to modifier 26, which identifies the professional component.

Question 33Coding Knowledge and Skills

In ICD-10-PCS, which character position identifies the body system?

  1. Second Correct answer.
  2. First
  3. Fourth
  4. Third

Explanation

The second character of an ICD-10-PCS code identifies the body system. The first character identifies the section, the third identifies the root operation, and the fourth identifies the body part.

Question 34Coding Knowledge and Skills

In the NCCI procedure-to-procedure edits, what does the Column Two code represent?

  1. The component code not separately payable with Column One Correct answer.
  2. An add-on code that is exempt from edits
  3. The primary procedure that is always separately payable
  4. A code that may be billed with modifier 59 without restriction

Explanation

In NCCI procedure-to-procedure edits, the Column Two code is the component or secondary code that is normally not separately payable with the Column One code. Payment may be allowed only when a proper modifier and documentation support separate reporting.

Question 35Coding Knowledge and Skills

When medical record documentation is ambiguous or conflicting, what is the coder's most appropriate action?

  1. Leave the diagnosis codes blank
  2. Assign codes based on the most likely diagnosis
  3. Query the physician for clarification Correct answer.
  4. Code only the presenting symptom

Explanation

Coders should not guess when documentation is unclear or contradictory. A physician query is used to obtain clarification that is supported by the record. The response should then be documented and used for code assignment.

Question 36Coding Knowledge and Skills

A surgical procedure that is planned in stages is reported with which modifier?

  1. 58 Correct answer.
  2. 76
  3. 78
  4. 79

Explanation

Modifier 58 indicates a staged or related procedure performed by the same physician during the postoperative period. It is used when the procedure was planned prospectively in stages or is more extensive than the original procedure.

Question 37Coding Knowledge and Skills

In ICD-10-PCS, a procedure in which a new device is put into a body part and left there is coded with which root operation?

  1. Supplement
  2. Insertion Correct answer.
  3. Replacement
  4. Revision

Explanation

Insertion is the root operation used when a nonbiological device is put into a body part without any existing device being removed. Replacement involves removing an existing device and putting in a new one.

Question 38Coding Knowledge and Skills

Which statement best describes a combination code in ICD-10-CM?

  1. A code that identifies laterality of a paired body part
  2. A code that requires two separate codes to fully describe a condition
  3. A single code classifying two diagnoses or a complication Correct answer.
  4. A code used only for inpatient principal diagnosis

Explanation

A combination code is a single code that classifies two diagnoses, a diagnosis with an associated complication, or a diagnosis with an associated manifestation. When a combination code fully describes the condition, additional codes are not assigned for those components.

Question 39Coding Knowledge and Skills

In the inpatient setting, a condition documented as "probable" should be coded as which of the following?

  1. Coded with an uncertain diagnosis code
  2. Symptom code only
  3. Coded as if it were confirmed Correct answer.
  4. Not coded until confirmed

Explanation

The inpatient coding guidelines allow coders to code probable, suspected, or likely conditions as though they were confirmed. This differs from outpatient coding, where uncertain diagnoses are generally not coded as confirmed.

Question 40Coding Knowledge and Skills

A patient with type 2 diabetes mellitus is documented as having diabetic stage 3a chronic kidney disease. According to ICD-10-CM, which code sequence is correct?

  1. E11.9, N18.31
  2. E11.22, N18.31 Correct answer.
  3. E11.65, N18.31
  4. N18.31, E11.22

Explanation

Type 2 diabetes mellitus with diabetic chronic kidney disease is classified with the combination code E11.22, and an additional code from category N18 is required to identify the stage of chronic kidney disease. The diabetes-with-CKD code is sequenced before the CKD stage code.

Question 41Coding Documentation

Which element is required in an operative report to support accurate code assignment?

  1. The insurance policy number and group ID
  2. The patient's home address and phone number
  3. The patient's occupation and employer
  4. The surgeon and any assistants Correct answer.

Explanation

An operative report must identify the surgeon and any assistants, the procedure performed, and the findings to support code assignment. Administrative data such as occupation, address, or insurance do not establish the procedure.

Question 42Coding Documentation

When the medical record is ambiguous and does not clearly support a code, what is the coder's best action?

  1. Assign the code that yields the highest reimbursement
  2. Query the provider for clarification Correct answer.
  3. Assign an unspecified code without contacting the provider
  4. Leave the code blank on the claim

Explanation

Coders may not assume or infer diagnoses; when documentation is ambiguous, a physician query is used to obtain clarification. Guessing or leaving the field blank can lead to inaccurate claims.

Question 43Coding Documentation

What is the purpose of an addendum in the medical record?

  1. To delete the original entry from the record
  2. To conceal an error in the documentation
  3. To replace the entire medical record
  4. To supplement the original entry Correct answer.

Explanation

An addendum supplements or clarifies an earlier entry without altering the original documentation. It must be dated and authenticated.

Question 44Coding Documentation

In an E/M note, the chief complaint is best described as which of the following?

  1. The physician's final diagnosis
  2. The patient's reason for care Correct answer.
  3. The review of systems
  4. The treatment plan for the visit

Explanation

The chief complaint is the patient's stated reason for seeking care, usually in the patient's own words. It is not the diagnosis, plan, or review of systems.

Question 45Coding Documentation

A late entry added to a medical record should include which of the following?

  1. The physician's home address
  2. The date and time the entry is being made Correct answer.
  3. The patient's insurance identification number
  4. The patient's occupational history

Explanation

A late entry must show the date and time it is written and be authenticated by the author. This preserves the integrity of the record.

Question 46Coding Documentation

Why is documentation of tobacco use important for coding?

  1. It supports tobacco use or dependence codes Correct answer.
  2. It is required on every claim regardless of encounter
  3. It determines the patient's insurance eligibility
  4. It replaces the need for a physical examination

Explanation

Tobacco use, dependence, and history have specific ICD-10-CM codes and may affect risk adjustment. Documentation supports code assignment when the condition is addressed.

Question 47Coding Documentation

The patient's physical status before anesthesia is documented using which system?

  1. ASA physical status Correct answer.
  2. Glasgow Coma Scale
  3. NYHA functional class
  4. APGAR score

Explanation

Anesthesia physical status is reported with the ASA physical status modifiers P1 through P6. APGAR, Glasgow, and NYHA assess other clinical conditions.

Question 48Coding Documentation

Which element is essential when documenting a wound for accurate code selection?

  1. The wound's length and depth Correct answer.
  2. The time of day the wound was examined
  3. The patient's dietary intake
  4. The patient's pain rating

Explanation

Wound repair codes depend on the length, depth, and complexity of the repair. Pain rating, time of day, and diet do not determine the code.

Question 49Coding Documentation

A patient has two lacerations of the same type repaired: one measuring 3 cm and one measuring 4 cm. How is the total length reported?

  1. Only the smaller wound, 3 cm
  2. Only the larger wound, 4 cm
  3. Each wound separately with no total length
  4. The sum of both wounds, 7 cm Correct answer.

Explanation

For multiple wounds of the same type and complexity, the lengths are added together to select the repair code. Reporting only one wound or separating them without summing can understate the service.

Question 50Coding Documentation

Using the Rule of Nines for an adult, what percentage of total body surface area is assigned to the entire head?

  1. 4.5%
  2. 18%
  3. 1%
  4. 9% Correct answer.

Explanation

In the adult Rule of Nines, the head and neck represent 9% of total body surface area. The arms are 9% each, the legs 18% each, and the trunk is divided into anterior and posterior 18% sections.