Certified Coding Associate Exam Certified Coding Associate Professional 4 — Questions and Answers
Question 1: According to UHDDS guidelines, what is the definition of 'other diagnoses' for inpatient reporting?
- All conditions mentioned in the discharge summary
- Conditions that coexist at admission or develop subsequently and affect patient care (Correct answer)
- Only conditions that require surgical intervention
- All chronic conditions regardless of treatment
Correct answer: Conditions that coexist at admission or develop subsequently and affect patient care
Per UHDDS, other diagnoses are conditions that coexist at the time of admission, develop subsequently, or affect patient care in terms of treatment, length of stay, or nursing care.
Question 2: A patient is seen in the ED and diagnosed with chest pain, rule out MI. The workup is negative. What is the correct coding approach for this outpatient visit?
- Code the MI as confirmed
- Code the chest pain as the reason for the visit (Correct answer)
- Code both chest pain and rule-out MI
- Leave diagnosis blank until confirmed
Correct answer: Code the chest pain as the reason for the visit
For outpatient encounters, uncertain diagnoses (rule-out, possible, probable) are not coded; instead, code the sign or symptom, such as chest pain.
Question 3: Which of the following is an example of a CPT Category II code?
- 0075T
- 99213
- 4011F (Correct answer)
- G0008
Correct answer: 4011F
CPT Category II codes (beginning with a number and ending in 'F') are optional tracking codes used for performance measurement.
Question 4: When coding an obstetric case, the trimester is based on which measurement?
- The number of fetuses
- The weeks of gestation at the time of the encounter (Correct answer)
- The estimated due date
- The mother's parity
Correct answer: The weeks of gestation at the time of the encounter
ICD-10-CM defines trimesters by weeks of gestation: first (less than 14 weeks), second (14–27 weeks), and third (27 weeks to delivery).
Question 5: What does HIPAA's minimum necessary standard require of healthcare providers?
- That providers share all patient information with insurers upon request
- That only the minimum amount of PHI needed to accomplish a task is used or disclosed (Correct answer)
- That patients consent to every disclosure of their records
- That medical records be stored for a minimum of 10 years
Correct answer: That only the minimum amount of PHI needed to accomplish a task is used or disclosed
The HIPAA minimum necessary standard requires covered entities to limit PHI use and disclosure to the least amount needed to accomplish the intended purpose.
Question 6: A patient is admitted with sepsis due to a urinary tract infection caused by E. coli. Which code is sequenced first?
- The UTI code
- The E. coli code
- The sepsis code (Correct answer)
- The organ dysfunction code
Correct answer: The sepsis code
Per ICD-10-CM guidelines, when sepsis and a localized infection are both present, sepsis is sequenced as the principal diagnosis.
Question 7: Which ICD-10-CM placeholder character is used when a code has fewer than the required number of characters?
- 0 (zero)
- X (Correct answer)
- Z
- 9
Correct answer: X
The letter 'X' is used as a placeholder in ICD-10-CM codes to allow for future expansion and to maintain the correct number of characters.
Certified Coding Associate Exam Certified Coding Associate Professional 4
According to UHDDS guidelines, what is the definition of 'other diagnoses' for inpatient reporting?