CCS Practice Test

CCS Coding Documentation Practice Questions

Coding Documentation makes up 10 of every 50 questions on a Tigertest CCS practice test. Here are 10 of the 40 questions on it, each with the answer and the reason.

Updated 2026-11-10 by the Tigertest team. Weighted to the AHIMA CCS Exam Content Outline. Original questions on coding guidelines and concepts; not affiliated with AHIMA.

1. 1. A consultant's diagnosis conflicts with the attending physician's. The coder:

   • A.Codes the attending's only
   • B.Queries the attending
   • C.Codes the consultant's
   • D.Codes both diagnoses

   Answer: B. Documentation from other physicians may be coded unless it conflicts with the attending's. When it does, the attending, who is responsible for the final diagnosis, is queried.

2. 2. Nursing notes say left hip, but the surgeon's note says right hip. The coder should:

   • A.Code the left side
   • B.Code the unspecified side
   • C.Code the right side
   • D.Query the attending

   Answer: D. Laterality may come from other clinicians, but when documentation conflicts, from the same clinician or different ones, the guidelines direct a query to the attending provider.

3. 3. The wound care nurse documents a stage 3 pressure ulcer, and the physician documents 'pressure ulcer.' The stage is coded from:

   • A.The wound nurse's note
   • B.A default stage 2
   • C.The physician's note only
   • D.The nursing flowsheet total

   Answer: A. Pressure ulcer stage, like BMI and depth of non-pressure ulcers, may be taken from other clinicians' documentation, but the provider must document the pressure ulcer itself.

4. 4. An NIH stroke scale score may be coded from a nurse's note when:

   • A.The patient is in the ICU
   • B.A neurologist is consulted
   • C.A provider documents stroke
   • D.The total score is over 10

   Answer: C. The NIHSS may be documented by clinicians other than the provider, but the associated diagnosis, the stroke, must be documented by the patient's provider.

5. 5. SDOH Z codes may be assigned from a patient's self-reported form when:

   • A.The payer asks for the codes
   • B.Registration scans it in
   • C.A clinician signs off on it
   • D.The patient dates the form

   Answer: C. Patient self-reported documentation may support SDOH codes as long as it is signed off by and incorporated into the health record by a clinician or provider.

6. 6. A dietitian documents criteria for severe malnutrition, but no provider mentions malnutrition. The coder:

   • A.Cannot code malnutrition yet
   • B.Codes unspecified malnutrition
   • C.Codes it from the BMI
   • D.Codes severe malnutrition

   Answer: A. Malnutrition is a diagnosis that the provider must document. The dietitian's assessment is a reason to query, not a basis for the code.

7. 7. The term 'urosepsis' in the record:

   • A.Codes to bacteremia
   • B.Codes to sepsis
   • C.Codes to a UTI
   • D.Has no default code

   Answer: D. Urosepsis is a nonspecific term with no code in ICD-10-CM. The provider must be queried for whether sepsis, a urinary tract infection or another condition is meant.

8. 8. A sputum culture grows Klebsiella, and the provider documents only 'pneumonia.' The coder:

   • A.Codes bacteremia too
   • B.Does not code the organism
   • C.Codes Klebsiella pneumonia
   • D.Codes a carrier state

   Answer: B. A causal organism cannot be assigned from a culture result alone. The provider must document the organism as the cause, so a query is the route to more specific coding.

9. 9. A breast cancer was excised, but the patient still receives adjuvant therapy for it. Code:

   • A.An encounter for follow-up
   • B.The active malignancy
   • C.A history of malignancy
   • D.An aftercare Z code

   Answer: B. When a primary malignancy has been excised but further treatment is directed to that site, the malignancy code is still assigned. The history code applies only when there is no further treatment and no evidence of disease.

10. 10. A condition after surgery is coded as a complication of care only when:

    • A.It was not present on admission
    • B.The coder sees a clear link
    • C.It starts within 30 days
    • D.The provider links it to care

    Answer: D. The term complication requires a cause-and-effect relationship between the care and the condition, plus an indication that it is a complication, documented by the provider. Query if unclear.