FREE CCDS Official Coding Guidelines and Regulatory Compliance Questions and Answers

Question 1

A patient is admitted with chest pain. After a full workup, myocardial infarction is ruled out, and the physician determines the cause of the chest pain to be gastroesophageal reflux disease (GERD). According to UHDDS guidelines, what is the principal diagnosis?

Accepted Answer

Gastroesophageal reflux disease (GERD)

Answer

The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. In this case, GERD was the final diagnosis determined to be the cause of the admission.

Question 2

In the inpatient setting, which of the following conditions documented at discharge should be coded as if it existed?

Accepted Answer

Possible pneumonia

Answer

The UHDDS guideline for reporting uncertain diagnoses states that if the diagnosis documented at discharge is qualified as 'probable,' 'suspected,' 'likely,' etc., the condition should be coded as if it existed. This rule applies only to inpatient admissions.

Question 3

What is the primary purpose of the Medicare 'Two-Midnight Rule'?

Accepted Answer

To determine if a hospital stay should be paid as inpatient (Part A) or outpatient (Part B).

Answer

The Two-Midnight Rule is a policy that guides admitting physicians on when to admit a patient as an inpatient. It generally considers a hospital stay spanning two midnights to be appropriate for inpatient payment under Medicare Part A.

Question 4

A CDS identifies conflicting information in the medical record regarding the cause of a patient's anemia. What is the most appropriate action?

Accepted Answer

Initiate a physician query for clarification.

Answer

The role of a CDS is to ensure documentation is clear, consistent, and complete. When documentation is conflicting or ambiguous, the appropriate action is to initiate a compliant, non-leading physician query to resolve the discrepancy.

Question 5

Which of the following would be considered a reportable secondary diagnosis?

Accepted Answer

Chronic hypertension managed with home medications that are continued during the stay.

Answer

According to UHDDS, a secondary diagnosis is a condition that coexists at admission or develops subsequently, and affects patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, or increased nursing care/monitoring.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

FREE CCDS Official Coding Guidelines and Regulatory Compliance Questions and Answers