Certified Coding Specialist (CCS) Exam

1. Question 1 · Coding Knowledge and Skills

   Discharge summary: 78-year-old admitted with fever, productive cough, worsening dyspnea and 3+ leg edema. Chest x-ray: right lower lobe infiltrate. BNP markedly elevated. Treated with IV ceftriaxone and azithromycin and with IV furosemide. Final diagnoses: Right lower lobe pneumonia; acute on chronic diastolic heart failure. Both conditions were equally responsible for this admission and both required inpatient treatment.

   Based on the documentation, which statement about the principal diagnosis is correct?
   • A.Dyspnea should be sequenced first because it prompted both workups
   • B.Either the pneumonia or the heart failure may be sequenced first
   • C.The heart failure must be sequenced first because it is a cardiac condition
   • D.The provider must be queried to choose a single principal diagnosis
   Show answer and explanation

   Answer: B. Either the pneumonia or the heart failure may be sequenced first

   When two or more interrelated or equally responsible conditions potentially meet the definition of principal diagnosis, either may be sequenced first unless the circumstances of admission, the therapy provided, or the Tabular List/Index indicate otherwise. Here the provider explicitly states both were equally responsible, so no query is needed; dyspnea is a symptom of the confirmed conditions and is not coded as principal.

2. Question 2 · Coding Documentation

   Operative report: Video-assisted thoracoscopic surgery, right. Three ports were placed. A 1.5 cm peripheral nodule in the right upper lobe was identified, and a wedge of lung tissue containing the nodule was removed with an endoscopic stapler. The remainder of the right upper lobe was left intact and expanded well.

   Which root operation and approach should be assigned for the wedge resection?
   • A.Excision, open approach
   • B.Resection, percutaneous endoscopic approach
   • C.Excision, percutaneous endoscopic approach
   • D.Resection, open approach
   Show answer and explanation

   Answer: C. Excision, percutaneous endoscopic approach

   Only a portion of the right upper lobe was removed, so the root operation is Excision; Resection requires removal of all of a body part, and the upper lobe has its own body part value. The surgeon's use of the word "resection" does not determine the root operation. A thoracoscopic (VATS) procedure through ports is the percutaneous endoscopic approach, not open.

3. Question 3 · Regulatory Compliance

   Attending progress note, day 2: Acute exacerbation of COPD. Continue nebulizers and IV steroids.

   Pulmonology consult, day 2: PFTs show fully reversible obstruction. Impression: acute asthma exacerbation. No evidence of COPD.

   Discharge summary (attending): Acute exacerbation of COPD, improved.

   What should the coder do next?
   • A.Query the attending to resolve the conflicting diagnoses
   • B.Code both acute COPD exacerbation and acute asthma exacerbation
   • C.Code acute asthma exacerbation because the specialist made it
   • D.Code COPD unspecified and omit the exacerbation
   Show answer and explanation

   Answer: A. Query the attending to resolve the conflicting diagnoses

   When the attending physician's documentation conflicts with a consultant's, the attending should be queried for clarification, because the attending is ultimately responsible for the final diagnostic statement. A consultant's opinion does not automatically override the attending. Coding both would report contradictory conditions, and dropping the exacerbation ignores documentation.

4. Question 4 · Provider Queries

   Query drafted by CDI specialist to Dr. Ortiz: "Patient admitted with COPD exacerbation. SpO2 86% on room air, respiratory rate 30, ABG pO2 54 mmHg, placed on BiPAP. Documenting acute respiratory failure would raise the DRG relative weight and improve our severity-of-illness profile. Please clarify the condition being treated: acute respiratory failure with hypoxia; hypoxemia without respiratory failure; other (please specify); clinically undetermined."

   Which change is required before this query can be sent?
   • A.Remove the ABG and oxygen saturation values from the query
   • B.Remove the sentence about the DRG weight and severity profile
   • C.Remove the option for clinically undetermined from the list
   • D.Replace the options with a yes/no question about respiratory failure
   Show answer and explanation

   Answer: B. Remove the sentence about the DRG weight and severity profile

   Compliant query guidelines prohibit stating the impact a response would have on reimbursement, DRG, or quality measures, so that sentence must go. The clinical indicators (SpO2, RR, ABG, BiPAP) belong in the query, and the multiple-choice options with other and clinically undetermined are appropriate; converting to yes/no for an undocumented diagnosis would make it leading.

5. Question 5 · Information Technologies

   Compliance audit summary: For two years, the billing office submitted claims using a default modifier set up in the billing system. Staff never checked whether it applied, despite repeated payer denial notices explaining the error. No one intended to defraud the government.

   Which statement about potential liability under the federal civil False Claims Act is accurate?
   • A.Liability can apply, since acting in reckless disregard of the truth meets the knowing standard
   • B.No liability can apply, since the Act requires proof of a specific intent to defraud
   • C.No liability can apply, since errors created by billing software are excluded from the Act
   • D.Liability can apply only if a whistleblower files suit within 60 days of the first claim
   Show answer and explanation

   Answer: A. Liability can apply, since acting in reckless disregard of the truth meets the knowing standard

   The civil False Claims Act defines "knowingly" to include actual knowledge, deliberate ignorance and reckless disregard of the truth, and expressly requires no proof of specific intent to defraud. Ignoring repeated notices of an error can meet that standard, and claims generated by software remain the submitter's responsibility.

6. Question 6 · Coding Knowledge and Skills

   Discharge summary: Patient with multiple myeloma, not in remission, admitted with fatigue and hemoglobin of 6.8 g/dL. Diagnosis: Symptomatic anemia due to the multiple myeloma (anemia in neoplastic disease). Transfused 2 units of packed red cells. No treatment directed at the myeloma was given during this stay.

   What is the correct sequencing for this admission?
   • A.Multiple myeloma, then anemia in neoplastic disease
   • B.Anemia in neoplastic disease, then multiple myeloma
   • C.Encounter for transfusion, then multiple myeloma
   • D.Anemia, unspecified, then multiple myeloma
   Show answer and explanation

   Answer: A. Multiple myeloma, then anemia in neoplastic disease

   When the admission is for management of anemia associated with the malignancy and treatment is only for the anemia, the malignancy is sequenced as the principal diagnosis, followed by the code for anemia in neoplastic disease. This differs from anemia due to chemotherapy (an adverse effect), where the anemia is sequenced first.

7. Question 7 · Coding Documentation

   Operative report: Hand-assisted laparoscopic sigmoid colectomy for recurrent diverticulitis. A hand port was placed through a 7 cm periumbilical incision and laparoscopic ports were added. The entire sigmoid colon was mobilized and removed, and a stapled colorectal anastomosis was created.

   Which root operation and approach should be assigned for the sigmoid colectomy?
   • A.Resection, open approach
   • B.Excision, percutaneous endoscopic approach
   • C.Excision, open approach
   • D.Resection, percutaneous endoscopic approach
   Show answer and explanation

   Answer: A. Resection, open approach

   The sigmoid colon has its own body part value and all of it was removed, so the root operation is Resection rather than Excision of the large intestine. Guideline B5.2a states that procedures performed with the open approach with percutaneous endoscopic assistance, or hand-assisted laparoscopy, are coded to the open approach.

8. Question 8 · Regulatory Compliance

   Cardiology consult, day 1: Troponin 0.09. Possible NSTEMI; trend troponins.

   Cardiology follow-up, day 2: Troponins flat at 0.08-0.09. Not an MI. Demand ischemia due to atrial fibrillation with rapid ventricular response.

   Discharge summary (attending): Atrial fibrillation with RVR, rate controlled. Demand ischemia; NSTEMI ruled out.

   Which cardiac conditions should be reported?
   • A.Atrial fibrillation, NSTEMI and demand ischemia
   • B.Atrial fibrillation and demand ischemia
   • C.Atrial fibrillation and NSTEMI
   • D.Atrial fibrillation only, after a query
   Show answer and explanation

   Answer: B. Atrial fibrillation and demand ischemia

   The early possible NSTEMI was later ruled out by the consultant, and the attending's discharge summary agrees, so there is no conflict to query. Inpatient uncertain diagnoses are coded only when still uncertain at discharge; a ruled-out condition is not coded. Demand ischemia was diagnosed and evaluated and is reported with the atrial fibrillation.

9. Question 9 · Provider Queries

   Discharge summary: Sepsis due to cellulitis of left lower leg, treated with oral cephalexin. Discharged day 2.

   Clinical data

   Measure	Admission	Day 2
   Temperature	37.4 C	37.0 C
   Heart rate	84	78
   Respiratory rate	16	16
   WBC	9,200	8,100
   Lactate	1.0 mmol/L	not drawn

   What should the coder do?
   • A.Send a clinical validation query presenting these findings and asking the provider to confirm or rule out sepsis
   • B.Send a query asking the provider to replace sepsis with cellulitis so the record supports the findings
   • C.Omit sepsis and code only the cellulitis, because the clinical data do not support the diagnosis of sepsis
   • D.Assign sepsis as principal diagnosis with no further action, because the discharge summary documents it
   Show answer and explanation

   Answer: A. Send a clinical validation query presenting these findings and asking the provider to confirm or rule out sepsis

   When a documented diagnosis appears to lack clinical support, the compliant step is a clinical validation query that presents the indicators and lets the provider confirm, rule out, or otherwise clarify the diagnosis. The coder may not remove a provider-documented diagnosis on the coder's own judgment, and a query that tells the provider which diagnosis to document is leading.

10. Question 10 · Coding Knowledge and Skills

    Query response from attending: "Stage 3 sacral pressure ulcer first noted by wound nurse 20 hours after admission. Patient arrived from home with limited skin assessment in ED. I am clinically unable to determine whether it was present at the time of admission."

    Which POA indicator applies, and how is it treated for HAC payment?
    • A.U, which is treated like Y, so the ulcer can still act as an MCC
    • B.W, which is treated like Y, so the ulcer can still act as an MCC
    • C.U, which is treated like N, so the ulcer cannot act as an MCC
    • D.W, which is treated like N, so the ulcer cannot act as an MCC
    Show answer and explanation

    Answer: B. W, which is treated like Y, so the ulcer can still act as an MCC

    When the provider states that it is clinically impossible to determine whether a condition was present on admission, POA indicator W applies, and CMS pays W like Y for HAC purposes. U is for documentation that is insufficient to determine POA status and is treated like N; here the provider answered the query, so the documentation is not insufficient.

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