CCDS Exam 2025: Practice Questions and Answers for Medical Coding, Exams of Nursing

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CCDS EXAM 2025 LATEST QUESTIONS

AND CORRECT ANSWERS GRADE A

A patient is admitted with pneumonia, stage 1 chronic renal failure, chronic anemia, and COPD, While hospitalized the patient receives IV antibiotics, inhalers, oxygen, IV fluids at 50mL/hr, and iron tablets. Keeping the guidelines for coding of secondary diagnoses in mind, which condition should be coded? A. Pneumonia only B. Pneumonia and COPD only C. Pneumonia, COPD, and anemia D. All of the conditions should be coded - ANSWER>>D. All of the conditions should be coded Which of the following is an example of a hospital-acquired condition? A. Fat embolism B. IV phlebitis C. Pneumonia D. Fractured ulna - ANSWER>>D. Fractured ulna Which of the following is an example of documentation that would meet the present on admission criteria for coding?

A. A diagnosis that is indicated in the history and physical and ruled out in the discharge summary B. A diagnosis found in a previous medical record C. A diagnosis that is listed as possible in the history and physical D. An acute condition identified on the third day of admission - ANSWER>>C. A diagnosis that is listed as possible in the history and physical A patient is admitted with abdominal pain and the history and physical indicated a diagnosis of probable colon cancer. On day two, the physician documents acute renal failure in the progress notes and the patient receives IV fluids. The discharge summary lists possible metastatic colon cancer and acute renal failure. The principal diagnosis would be: A. Colon cancer B. Acute renal failure C. Abdominal pain D. Metastatic neoplasm of the colon - ANSWER>>A. Colon cancer Accurate documentation should:

1. Include identification of the patient's SOI 2. Identify conditions that are present on admission 3. Support medical necessity A. 1 and 2 B. 2 and 3

A patient comes to the ED with fever, chills, and knee pain. Documentation states that the patient's admission is for knee prosthesis removal due to infection. What is the principal diagnosis? (Do not include the procedure) A. Fever B. Sepsis C. Infected knee prosthesis D. Knee pain - ANSWER>>C. Infected knee prosthesis A patient is admitted from the emergency department (ED) with a diagnosis of weakness and anemia. After admission and further treatment with packed red blood cells (PRBC), GI consult, and endoscopy, the physician includes the following diagnoses in the discharge summary: anemia, suspected bleeding gastric ulcer, and GERD. What would be the most appropriate principle diagnosis? A. Bleeding gastric ulcer B. Anemia C. GERD D. Weakness - ANSWER>>A. Bleeding gastric ulcer A patient is admitted with new-onset seizures. Head CT reveals a mass in the occipital region. The physician documents possible brain tumor, and the patient is transferred to another hospital for further workup. What would be the most appropriate principal diagnosis based upon this documentation?

A. Seizure B. Neoplasm of occipital region C. Head mass D. Head tumor - ANSWER>>B. Neoplasm of occipital region A hospital's base rate or blended rate is:

1. Calculated annually 2. Dependent upon indirect costs for graduate medical education and new technology 3. Adjusted based upon number of low-income patients cared for 4. Not adjusted based upon capital expenses

A. 1 and 2

B. 2 and 3 C. 1,2, and 3 D. 1,2,3, and 4 - ANSWER>>C. 1,2, and 3

1. Calculated annually 2. Dependent upon indirect costs for graduate medical education and new technology 3. Adjusted based upon number of low-income patients cared for

C. Osteomyelitis D. Septic joint - ANSWER>>D. Septic joint Which guideline provides the direction for the correct assignment of the principal diagnosis? A. Probable/possible conditions should always be assigned over a symptom diagnosis B. Always code the most severe condition as principal C. The coder can link the symptom to the most appropriate condition D. A sign and symptom code should only be used if no definitive diagnosis is determined - ANSWER>>D. A sign and symptom code should only be used if no definitive diagnosis is determined. A patient is admitted with hypertensive heart failure and chronic kidney disease (CKD). Appropriate code assignment would: A. Identify individual codes for each condition B. Identify the most appropriate combination code C. Require a query for a link between the conditions D. Utilize a combination code with the individual codes listed as secondary - ANSWER>>D. Utilize a combination code with the individual codes listed as secondary A patient is admitted with exacerbation of COPD, acute respiratory failure, and acute renal failure. Appropriate sequencing of the conditions would be based upon:

1. Coding guidelines stating that if two conditions meet the criteria for principal diagnosis, either condition can be sequenced first 2. Coding guidelines indicating chapter-specific guidelines 3. Understanding of the UDHHS definition of a principal diagnosis A. 1 and 2 B. 2 and 3 C. 1 and 3 D. 1,2, and 3 - ANSWER>>D. 1,2, and 3 1. Coding guidelines stating that if two conditions meet the criteria for principal diagnosis, either condition can be sequenced first 2. Coding guidelines indicating chapter-specific guidelines 3. Understanding of the UDHHS definition of a principal diagnosis Which of the following are included in chapter-specific guidelines for the coding of HIV? 1. ICD-10 code B20 should be sequenced as principal diagnosis in all cases 2. ICD-10 code B20 should only be assigned in confirmed cases of HIV 3. HIV status must be confirmed by a blood test 4. ICD-10 code B20, if sequenced as a secondary diagnosis, qualifies as an MCC 5. Coding is specific to the reason for admission A. 1,2, and 3

C. Bone metastasis D. Palliative care - ANSWER>>C. Bone metastasis When coding a medical record that includes diabetes and manifestations of diabetes, it is important to remember that specificity of coding for diabetes is dependent upon:

1. Documentation of Type 1 or Type 2 diabetes 2. Documentation of whether the diabetes is controlled 3. Documentation of the patient's blood sugar levels 4. Documentation of any manifestations of the diabetes

A. 1,2, and 5

B. 1,2, and 12

C. 1 and 45

D. 2 and 4 - ANSWER>>C. 1 and 4

1. Documentation of Type 1 or Type 2 diabetes
2. Documentation of any manifestations of the diabetes A late effect of a condition is defined as: A. A condition that develops within a year of the original condition B. A condition that always occurs

C. A condition that remains or develops after conclusion of the acute phase of an illness/injury D. A condition that occurs as a complication of surgery - ANSWER>>C. A condition that remains or develops after conclusion of the acute phase of an illness/injury A patient is admitted from a nursing home with pneumonia. Nursing notes identify a decubitus ulcer that is described as a stage 3 ulcer of the sacrum. The physician documentation does not indicate the ulcer, but a wound care consult is ordered and a wound vacuum is placed. Which of the following statements is accurate? A. The ulcer would not be coded as it is a hospital-acquired condition B. The ulcer would be coded as an MCC to the pneumonia C. The ulcer would be coded as principal diagnosis D. The ulcer would not be coded as the physician has not provided its etiology or location - ANSWER>>D. The ulcer would not be coded as the physician has not provided its etiology or location The purpose of a concurrent query is to:

1. Ensure that each medical record accurately reflects the patient's SOI and the resource consumption of the admission 2. Provide physicians with necessary information so they can better understand coding guidelines 3. Assist in the accurate coding of diagnoses being monitored and treated 4. Eliminate retrospective queries

3. The specificity or degree of severity of a condition 4. Conditions that were present on admission When formulating a credible clinical query for a physician, which of the following information should a CDI specialist incorporate? A. Medical history of the patient, past medications, and current medications B. Risk factors of a condition, signs and symptoms of a condition, and treatment C. Treatment plan for the admission D. Possible DRG choices for the physician to review - ANSWER>>B. Risk factors of a condition, signs and symptoms of a condition, and treatment Policies and procedures that spell out a concurrent query process are important to: A. Ensure that retrospective queries do not occur B. Stipulate conformance to AHIMA guidelines C. Identify conditions for when and how a query will be formulated D. Prevent the need for coding audits - ANSWER>>C. Identify conditions for when and how a query will be formulated Metabolic encephalopathy is: A. Treated by correcting the underlying condition B. Caused by trauma to the head

C. A minor comorbid condition D. Usually the principal diagnosis - ANSWER>>A. Treated by correcting the underlying condition A patient is admitted with new-onset severe headache, visual changes, difficulty swallowing, and hypertension (HTN). Clinically, which of the diagnoses below would best explain these symptoms? A. Arteriosclerosis B. Cerebral edema secondary to a lesion in the brain C. Acute renal failure D. Lou Gehrig's disease - ANSWER>>B. Cerebral edema secondary to a lesion in the brain An elderly gentleman with a history of COPD and HTN who uses home oxygen is admitted with complaints of dyspnea, rapid shallow breaths, and an oxygen saturation of 84% on 2L of oxygen. A non-rebreather mask is applied, and the patient receives IV solumedrol and breathing treatments. The physician documents in the progress notes "respiratory failure due to COPD versus pneumonia." Based upon this documentation, the principal diagnosis would be: A. Dyspnea B. Pneumonia C. COPD D. Respiratory failure - ANSWER>>D. Respiratory failure

B. Community acquired C. Gram negative D. Pneumococcal - ANSWER>>C. Gram negative A patient is admitted with fever, shortness of breath, chest pain, and nonproductive cough. Chest x-ray confirms a pleural effusion. Which type of effusion is most probable for this patient? A. Malignant B. Transudative C. Exudative D. Serosanguinous - ANSWER>>C. Exudative Clinical indicators of acute respiratory failure most commonly include:

1. Use of accessory muscles 2. Work of breathing 3. Inability to speak more than a few words at a time 4. Oxygen saturations below 95% on 2L oxygen 5. Tachycardia A. 1,2, and 3 B. 2,3, and 5 C. 3,4, and 5 D. 1,3, and 5 - ANSWER>>A. 1,2, and 3

1. Use of accessory muscles 2. Work of breathing 3. Inability to speak more than a few words at a time An elderly patient with a history of CAD, GERD, and HTN is admitted with chest pain. Pain was unrelieved with nitroglycerin at home. A GI cocktail is administered in the ED with relief. Cardiac workup is negative, and patient is scheduled for an EGD. The physician documents atypical chest pain. A concurrent query: A. Is not necessary to code GERD as the principal diagnosis B. Would be needed to specify the cause of the chest pain C. Would not be necessary as chest pain is the principal diagnosis D. Would be needed to specify the type of GERD - ANSWER>>B. Would be needed to specify the cause of the chest pain A patient is admitted with syncope. Typical considerations for the underlying cause of syncope include: A. Cardiac arrhythmia and fluid overload B. CHF and renal failure C. Diabetes, bradycardia, and dehydration D. Obesity and colon cancer - ANSWER>>C. Diabetes, bradycardia, and dehydration

B. A non-reimbursable procedure was performed C. The procedure had to be performed via an incision and will lead to a different surgical MS-DRG D. A complication that will code as an MCC - ANSWER>>C. The procedure had to be performed via an incision and will lead to a different surgical MS-DRG It is important to clarify the type of debridement that is performed during a patient's hospital stay because debridement: A. Is not reimbursable if performed by wound care nurses B. Should be identified by the type of debridement and the depth of tissue removed C. Is a hospital-acquired condition that does not provide reimbursement D. Is not reimbursable if performed at the bedside - ANSWER>>B. Should be identified by the type of debridement and the depth of tissue removed Which of the following would be an important indicator of severe malnutrition? A. Albumin of 2. B. Poor or delaying wound healing C. Patient is 90% of ideal body weight D. Patient is NPO after midnight for surgery scheduled the next day - ANSWER>>B. Poor or delaying wound healing

A patient is admitted with weakness, dehydration, and AMS. The patient also has a history of CKD stage 2 with a baseline creatinine of 1.6, CHF, HTN, and CABG. Blood urea nitrogen (BUN) is 32, creatinine is 2.4, and urine analysis is positive for white blood cells. Head CT is negative for acute changes. The patient is started on IV fluids and antibiotics. Labs after 2 liters of fluid are BUN 28 and creatinine 1.7. The physician documents the following impression list:

• Dehydration with pre-renal azotemia
• UTI
• CKD
• AMS Which of the following is an appropriate concurrent query? A. Documentation indicates creatinine 2.4 on admission decreasing to 1. after 2 liters of fluid administered. Please clarify the condition you are monitoring and treating related to creatinine. Based upon presentation of altered mental status, are you also treating a CVA? B. Please specify the reason for the IV fluids C. Please specify the - ANSWER>>A. Documentation indicates creatinine 2. on admission decreasing to 1.7 after 2 liters of fluid administered. Please clarify the condition you are monitoring and treating related to creatinine. Based upon presentation of altered mental status, are you also treating a CVA? Treatment of acute renal failure may include: