Latest PDF of AHIMA-CCS: Certified Coding Specialist

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AHIMA-CCS exam Format | Course Contents | Course Outline | exam Syllabus | exam 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 (CPC) (ICD-10-CM)
http://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?
A. Z85.3
B. Z86.11
C. Z87.891
D. Z90.11
Answer: A
Explanation: The correct ICD-10-CM code to report a patient's personal history
of breast cancer is Z85.3. This code is used to indicate a personal history of
malignant neoplasm, and the additional characters can be used to specify the
type and location of the cancer.
Question: 563
Admission Date: 4/24
Discharge Date: N/A
Admitting Diagnosis: Non-ST elevation myocardial infarction (NSTEMI)
Chief Complaint: A 62-year-old male presented to the emergency department
with chest discomfort, diaphoresis, and shortness of breath.
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
B. I21.9
C. I21.0
D. I21.1
E. I21.2
F. I21.3
G. I21.9 and I50.9
Answer: A
Explanation: The principal ICD-10-CM code for this encounter should be
I21.4. The patient presented with symptoms and was diagnosed with non-ST
elevation myocardial infarction (NSTEMI). The I21.4 code represents non-ST
elevation (NSTEMI) myocardial infarction, which accurately describes the
condition in this scenario. The clinical presentation, electrocardiogram findings,
and elevated cardiac enzyme levels support the selection of this code.
Additional codes for hypertension (I10), hyperlipidemia (E78.5), and diabetes
mellitus (E11.9) may also be assigned as secondary diagnoses if documented
and supported by the medical record.
Question: 564
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
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
appropriate when the physician performs a detailed history, detailed
examination, and moderate complexity medical decision-making.
Question: 565
A patient undergoes a left total mastectomy with axillary lymph node dissection
for breast cancer. Which CPT code should be assigned for this procedure?
A. 19303
B. 19304
C. 19305
D. 19307
Answer: C
Explanation: The correct CPT code for a left total mastectomy with axillary
lymph node dissection is 19305. This code is used when the entire breast tissue
is removed, along with lymph node dissection.
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
Explanation: The correct CPT code(s) for this scenario are:
45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other
lesion(s) by snare technique)
88305 (Surgical pathology, gross and microscopic examination for tumor,
polyp, or other lesion [except for Mohs surgery]; single specimen)
In this case, the patient undergoes a colonoscopy with removal of a small polyp
in the sigmoid colon, and the polyp is sent for biopsy. The biopsy confirms the
polyp to be benign. Therefore, option A is the correct answer, as it includes the
appropriate CPT code for the colonoscopy with removal of the polyp.
Question: 567
Which of the following ICD-10-CM codes is used to report a deep vein
thrombosis (DVT) of the right lower extremity?
A. I82.421
B. I82.422
C. I82.431
D. I82.432
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?
A. 11200
B. 11201
C. 11202
D. 11204
Answer: C
Explanation: The correct CPT code to report for the removal of multiple skin
tags using electrosurgery is 11202. This code is appropriate when the physician
removes 2 to 14 skin tags.
Question: 569
A patient is admitted to the hospital with a diagnosis of pneumonia due to
Streptococcus pneumoniae. Which ICD-10-CM code represents the appropriate
diagnosis for this patient?
A. J13.0
B. 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
Which of the following is true regarding the coding of external cause of
morbidity in ICD-10-CM?
A. External cause codes are required for all healthcare encounters
B. External cause codes are used to indicate the intent of an injury or poisoning
C. External cause codes are only used for inpatient encounters
D. External cause codes are found in Chapter 20 of ICD-10-CM
Answer: B
Explanation: External cause codes in ICD-10-CM are used to provide
additional information about the cause, intent, and circumstances of an injury,
poisoning, or other external events. They are not required for all healthcare
encounters, but they may be used when documenting the cause of an injury or
the intent behind a poisoning. External cause codes can be used for both
inpatient and outpatient encounters and can be found in Chapter 20 of ICD-10-
CM.
Question: 571
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: B
Explanation: 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.
Which of the following ICD-10-CM codes is used to report a nontraumatic
subarachnoid hemorrhage?
A. I60.01
B. I60.02
C. I60.11
D. I60.12
Answer: A
Explanation: The ICD-10-CM code I60.01 is used to report a nontraumatic
subarachnoid hemorrhage. The code I60.01 represents a nontraumatic
subarachnoid hemorrhage from carotid siphon and bifurcation.
Question: 572
A patient undergoes a diagnostic bronchoscopy with bronchoalveolar lavage for
the evaluation of a lung infection. Which CPT code should be assigned for this
procedure?
A. 31622
B. 31623
C. 31625
D. 31628
Answer: B
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
Admission Date: 2/24
Discharge Date: N/A
Admitting Diagnosis: Major depressive disorder, single episode, moderate
Chief Complaint: A 40-year-old female presented to the psychiatrist's office
with a depressed mood, loss of interest, and feelings of worthlessness.
Past Medical History: None documented
Physical Exam:
General: Poor eye contact, psychomotor retardation
Psychiatric: Depressed affect, anhedonia
Impression: The patient was diagnosed with major depressive disorder, single
episode, moderate based on the clinical presentation and psychiatric evaluation.
Plan: The patient was prescribed an antidepressant medication and referred for
psychotherapy.
What should the principal ICD-10-CM code be for this encounter?
A. F32.1
B. F32.9
C. 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
Answer: A
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
disorder (F41.9) or other relevant diagnoses may also be assigned as secondary
diagnoses if documented and supported by the medical record.
Question: 574
Which ICD-10-CM code is used to report a patient's personal history of breast
cancer in the left breast?
A. Z85.3
B. Z86.11
C. Z87.891
D. Z90.11
Answer: A
Explanation: The correct ICD-10-CM code to report a patient's personal history
of breast cancer in the left breast is Z85.3. This code is used to indicate a
personal history of malignant neoplasm, and the additional characters can be
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
should be assigned for this condition?
A. I21.09
B. I21.01
C. I21.11
D. I21.31
Answer: B
Explanation: The correct code for a STEMI of the anterior wall is I21.01 (ST
elevation (STEMI) myocardial infarction involving left main coronary artery).
Option A (I21.09) represents other ST elevation (STEMI) myocardial
infarction, option C (I21.11) represents ST elevation (STEMI) myocardial
infarction involving left anterior descending coronary artery, and option D
(I21.31) represents ST elevation (STEMI) myocardial infarction involving
other coronary artery of anterior wall.
Question: 576
A patient presents to the clinic for a routine mammogram. The mammogram
shows a suspicious mass, and a subsequent biopsy confirms a diagnosis of
invasive ductal carcinoma of the breast. Which ICD-10-CM code should be
assigned for the biopsy procedure?
A. 85.11
B. 85.12
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
breast.
Question: 577
Radiology
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 radiologist, who noted stable findings without any signs of recurrence or
new abnormalities. The radiologist provided a final impression of negative
mammogram.
What CPT code should be reported for the follow-up mammogram?
A. 77065
B. 77066
C. 77067
D. 77068
Answer: C
Explanation: The correct CPT code for the follow-up mammogram is 77067.
This code represents screening mammography, bilateral (two views of each
breast), and is used for routine surveillance or follow-up mammograms. Codes
77065 and 77066 represent diagnostic mammography for unilateral and
bilateral examinations, respectively, and code 77068 represents a diagnostic
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.
Which CPT code should be assigned for this procedure?
A. 59510
B. 59514
C. 59515
D. 59525
Answer: C
Explanation: The correct CPT code for a cesarean section delivery for a breech
presentation is 59515. This code is used when a cesarean section is performed
for a nontransverse or oblique lie presentation, such as a breech presentation.
Question: 579
Admission Date: 1/24
Discharge Date: N/A
Admitting Diagnosis: Acute exacerbation of chronic obstructive pulmonary
disease (COPD)
Chief Complaint: A 60-year-old male presented to the emergency department
with increased shortness of breath, wheezing, and coughing up yellowish
sputum.
Past Medical History: Chronic obstructive pulmonary disease (COPD),
smoking history
Physical Exam:
General: Increased respiratory effort
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.
What should the principal ICD-10-CM code be for this encounter?
A. J44.0
B. J44.1
C. J44.9
D. J44.0 and F17.210
E. J44.0 and Z87.891
F. J44.0 and Z87.01
G. J44.0 and J44.9
H. J44.0 and J44.1
Answer: A
Explanation: The principal ICD-10-CM code for this encounter should be
J44.0. The patient presented with symptoms and was diagnosed with an acute
exacerbation of chronic obstructive pulmonary disease (COPD). The J44.0 code
represents chronic obstructive pulmonary disease with acute lower respiratory
infection, which accurately describes the condition in this scenario. The clinical
presentation, physical examination findings, and medical history support the
selection of this code. Additional codes for tobacco use disorder (F17.210) or
other relevant diagnoses may also be assigned as secondary diagnoses if
documented and supported by the medical record.
Question: 580
Which ICD-10-CM code is used to report a patient's personal history of non-
Hodgkin lymphoma?
A. Z85.79
B. Z86.010
C. Z87.891
D. Z90.11
Answer: A
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.
Question: 581
Which of the following is an example of unbundling in coding?
A. Reporting multiple services provided during a single patient encounter
B. Combining two or more codes into a single code
C. Coding a symptom instead of a confirmed diagnosis
D. Separating a procedure into its component parts and coding each part
separately
Answer: D
Explanation: Separating a procedure into its component parts and coding each
part separately. Unbundling occurs when a procedure is broken down into its
individual components, and each component is coded and billed separately,
instead of reporting the procedure as a whole. This practice is considered
inappropriate coding and can result in overpayment. Reporting multiple
services provided during a single patient encounter (A) is not unbundling if 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.
Question: 582
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?
A. F32.9, Z79.891
B. F33.9, Z79.891
C. F32.0, Z79.891
D. F33.0, Z79.891
Answer: A
Explanation: The correct ICD-10-CM codes for this scenario are:
F32.9 (Major depressive disorder, single episode, unspecified)
Z79.891 (Long-term (current) use of selective serotonin reuptake inhibitors
[SSRIs])
In this case, the patient is diagnosed with major depressive disorder and started
on pharmacotherapy with an SSRI antidepressant. Therefore, option A is the
correct answer, as it includes the appropriate ICD-10-CM codes for the
diagnosis and medication.
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