CCS (Certified Coding Specialist): AHIMA (American Health Information Management Association) oversees this Certification and it is also called as hospital facility coding.
Check marks for CCS Certification:
The CCS Certification exam composes of 97 multiple-choice questions (79 scored/18 pre-test) and 8 medical scenarios (6 scored/2 pre-test) based on the content of CPT (Medical and Surgical Procedures codes), ICD-10-CM (Diagnoses and External cause codes), HCPCS level II (Drugs and Supplies codes), ICD-10- PCS (ICD-10 Procedure Coding System), billing and terminology related to Hospital setting.
CCS Exam syllabus breakdown:
Section 1-Clinical Documentation:
Encounter type of the patient need to be confirmed. Analyze electronic medical record (EMR) documentation to classify diagnoses and procedures which can be coded and reported. Ascertain the necessity of additional clinical documentation required. Liaise with healthcare providers to secure appropriate clinical documentation. Formulate a compliant physician query
Section 2 - Diagnosis Coding:
Report the ICD-10-CM diagnoses according to current coding guidelines for inpatient and outpatient services. Sequence diagnoses according to the ICD-10-CM conventions and current chapter specific coding guidelines. Refer appropriate materials to ease the process of diagnosis coding.
Section 3 - Procedure Coding
Report procedure codes according to current coding guidelines for inpatient and outpatient services. Arrange and apply the official ICD-10-PCS, CPT/HCPCS Level II procedure coding guidelines. Refer appropriate materials to ease the process of procedure coding.
Section 4 - Reporting Requirements for Inpatient Services
Report the POA indicators as per UHDDS guidelines. Authenticate DRG assignment based on the Inpatient Prospective Payment System (IPPS) definitions and guidelines. Classify the impact of code selection of severity of illness (SOI)/risk of mortality (ROM) assignment on All Patients Refined Diagnosis Related Groups(APR-DRG). Classify the impact of code selection of MCC/CC assignment on MS-DRG. Authenticate the discharge disposition and determine coding edits (e.g., Medicare Code Editor (MCE)
Section 5 - Reporting Requirements for Outpatient Services
Report modifiers based on the procedure performed and reporting requirements. Report E & M level codes for facility reporting based on place of service, type of service and patient status. Authenticate Ambulatory payment classifications (APC) assignment based on Outpatient Prospective Payment System (OPPS) definitions. Determine coding edits (e.g., National Correct Coding Initiative (NCCI), Medicare Code Editor (MCE) and Outpatient Code Editor (OCE)
Section 6 - Data Quality Management
Determine the quality of coded data and health record documentation. Interact with clinical providers regarding reimbursement techniques and documentation requirements related to coding. Determine the accuracy of abstracted data and report compliance concerns. Determine internal and external audit findings for maintaining transparency.
Section 7 - Privacy, Confidentiality, Legal, and Ethical Issues
Affix policies and procedures for access and disclosure of Protected Health Information (PHI). Report privacy or security concerns. Affix AHIMA Code of Ethics/Standards of Ethical Coding.
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Email:
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