CCS Sample Multiple-choice Questions and Answer Key
1. A patient was discharged from the hospital with a diagnosis of bronchial asthma.
Upon reviewing the record, the coder notes the patient was described as having
prolonged and intractable wheezing, airway obstruction not relieved by
bronchodilators, and a decreased PAO2 lab value. The physician should be
queried to determine whether the code for ___________is appropriate as the
Acute viral Bronchitis
2. A patient was admitted to the hospital with severe dehydration and malnutrition.
His blood sugar was elevated. The patient is a known alcohol abuser.
Intravenous fluid replacement was given to hydrate the patient, who signed out
against medical advice after two days. Final diagnoses were: severe dehydration
with malnutrition and adult-onset diabetes vs. early cirrhosis associated with
alcoholism. The principal diagnosis is:
Cirrhosis of liver due to alcoholism
3. A patient is admitted to the hospital to undergo a radical mastectomy for
recurrent carcinoma of the breast (Previously, she had elected to have a
lumpectomy). The attending physician lists a history of atrial fibrillation as a
secondary diagnosis. The patient is currently not on any medication. For medical
clearance prior to surgery, the patient is seen by a consultant, who says that the
patient was satisfactory for the procedure. The coder should:
Report atrial fibrillation as a current condition, because it was documented
by the physician in the history.
Code atrial fibrillation as a current condition, because the patient was seen
by a consultant for surgical clearance.
Add the code for observation for suspected cardiovascular condition
Omit reporting the code for atrial fibrillation, because it was not treated
and did not affect the course of treatment.