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Exam Number : AHIMA-CCS
Exam Name : Certified Coding Specialist (ICD-10-CM)
Vendor Name : Medical
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AHIMA-CCS test Format | AHIMA-CCS Course Contents | AHIMA-CCS Course Outline | AHIMA-CCS test Syllabus | AHIMA-CCS test Objectives

Number of Questions on exam:
=> 97 multiple-choice questions (79 scored/18 pretest)
=> 8 medical scenarios (6 scored/2 pretest)
Exam Time: 4 hours no breaks
Domain 1 Health Information Documentation (8-10%)
1. Interpret health record documentation using knowledge of anatomy, physiology, clinical indicators and disease processes, pharmacology and medical terminology to identify codeable diagnoses and/or procedures
2. Determine when additional clinical documentation is needed to assign the diagnosis and/or procedure code(s)
3. Consult with physicians and other healthcare providersto obtain further clinical documentation to assist with code assignment
4. Compose a compliant physician query
5. Consult reference materialsto facilitate code assignment
6. Identify patient encounter type
7. Identify and post chargesfor healthcare services based on documentation

Domain 2 Diagnosis & Procedure Coding (64-68%)
1. Select the diagnosesthat require coding according to current coding and reporting requirementsfor acute care (inpatient) services
2. Select the diagnosesthat require coding according to current coding and reporting requirementsfor outpatient services
3. Interpret conventions, formats, instructional notations, tables, and definitions of the classification system to select diagnoses, conditions, problems, or other reasonsfor the encounter that require coding
4. Sequence diagnoses and other reasons for encounter according to notations and conventions of the classification system and standard data set definitions(such as Uniform Hospital Discharge Data Set [UHDDS])
5. Apply the official ICD-10-CM coding guidelines
1. Select the proceduresthat require coding according to current coding and reporting requirementsfor acute care (inpatient) services
2. Select the proceduresthat require coding according to current coding and reporting requirementsfor outpatient services
3. Interpret conventions, formats, instructional notations, and definitions of the classification system and/ornomenclature to select procedures/servicesthat require coding
4. Sequence procedures according to notations and conventions of the classification system/nomenclature and standard data set definitions(such as UHDDS)
5. Apply the official ICD-10-PCS procedure coding guidelines
6. Apply the official CPT/HCPCS Level II coding guidelines

Domain 3 Regulatory Guidelines and Reporting Requirements for Acute Care (Inpatient) Service (6-8%)
1. Select the principal diagnosis, principal procedure, complications, comorbid conditions, other diagnoses and proceduresthat require coding according to UHDDS definitions and Coding Clinic
2. Assign the present on admission (POA) indicators
3. Evaluate the impact of code selection on Diagnosis Related Group (DRG) assignment
4. Verify DRG assignment based on Inpatient Prospective Payment System (IPPS) definitions
5. Assign and/or validate the discharge disposition

DOMAIN 4. Regulatory Guidelines and Reporting Requirements for Outpatient Services (6-8%)
1. Select the reason for encounter, pertinentsecondary conditions, primary procedure, and other proceduresthat require coding according to UHDDS definitions, CPT Assistant, Coding Clinic, and HCPCS
2. Apply Outpatient Prospective Payment System (OPPS) reporting requirements:
a. Modifiers
b. CPT/ HCPCS Level II
c. Medical necessity
d. Evaluation and Management code assignment (facility reporting)
3. Apply clinical laboratory service requirements

DOMAIN 5. Data Quality and Management (2-4%)
1. Assess the quality of coded data
2. Communicate with healthcare providersregarding reimbursementmethodologies, documentation rules, and regulationsrelated to coding
3. Analyze health record documentation for quality and completeness of coding
4. Review the accuracy of abstracted data elementsfor database integrity and claims processing
5. Review and resolve coding edits such as Correct Coding Initiative (CCI), Medicare Code
Editor (MCE) and Outpatient Code Editor (OCE)

DOMAIN 6. Information and Communication Technologies (1-3%)
1. Use computer to ensure data collection,storage, analysis, and reporting of information.
2. Use common software applications(for example, word processing,spreadsheets, and email) in the execution of work processes
3. Use specialized software in the completion of HIM processes

DOMAIN 7. Privacy, Confidentiality, Legal, and Ethical Issues (2-4%)
1. Apply policies and proceduresfor access and disclosure of personal health information
2. Apply AHIMA Code of Ethics/Standards of Ethical Coding
3. Recognize and report privacy and/or security concerns
4. Protect data integrity and validity using software or hardware technology

DOMAIN 8. Compliance (2-4%)
1. Evaluate the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards
2. Monitor compliance with organization-wide health record documentation and coding guidelines
3. Recognize and report compliance concerns

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Incoming students - Immunization records

Be organized to give your required immunization facts via an internet portal ahead of August 1.

proposing evidence of a previous COVID-19 infection or  COVID-19 Vaccination

Please use MedProctor to publish previous fantastic COVID-19 vaccinations and COVID-19 diagnoses, although you submitted consequences via e mail in the past. The MedProctor Portal can be used to assess exemptions to the Miami COVID-19 checking out program, and to examine when students are eligible to return to the pool of broad-web and surveillance trying out. by means of uploading your documentation, you're allowing your check result/vaccination checklist to be shared with the Miami COVID-19 testing and response groups, as essential, to be able to exempt you from trying out, isolation, and/or quarantine.

There is no can charge for this provider, notwithstanding you've got the option to buy a membership, so as to supply lifetime entry to your very own fitness information that may also be shared with others, as you designate. 

the 1st step: Register

Incoming students: if you are a brand new student, register using the link you acquired to your Miami email account (from MedProctor) to expedite your registration. in case you can't locate the e mail, which you can talk over with and register to start a new account. classification to your Miami e mail handle to get begun and follow the directions to register for a new account. 

For COVID-19 vaccinations: if you are already registered with MedProctor, consult with and sign in the use of the login counsel you set up when you all started at Miami college. 

Step Two: download

Incoming students: Fill out any required assistance. down load the mandatory types and follow the instructions provided. The form requires a doctor's signature. Preview the immunization guidelines and certification (PDF).

For COVID-19 vaccinations: when you are submitting COVID-19 information, you do not need to get a separate kind. move on to the next step.

Step Three: upload

Incoming students: Log lower back in to your MedProctor account and add a replica of your varieties. be sure your varieties are finished and legible. you are going to get hold of an e-mail affirmation once the forms have been reviewed (can also take three-7 days).

For COVID-19 vaccinations: add a picture of your COVID-19 vaccine card (front and returned). select "COVID Vaccine" or "supporting Documentation" within the dropdown menu. you are going to receive an electronic mail affirmation from MedProctor when your vaccination documentation has been reviewed (can also take 3-7 days). 

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Confidentiality of SHS treatment statistics

The clinical checklist of remedy received at the scholar fitness provider (SHS) is considered exclusive counsel and may most effective be launched beneath certain conditions.

students may also initiate unlock of their medical guidance with the SHS body of workers. The free up ought to be in writing; types are available on the SHS. If students are faraway from campus, a signed authorization from the scholar patient remains fundamental. Authorizations have to consist of name, Banner Identification quantity, date remaining attended/or graduated from Miami, where the assistance should still be despatched, the pupil's signature and date. Authorizations dated greater than three months earlier than receipt should not approved. Faxed requests are appropriate at 513-529-1892.

in addition, student health carrier personnel may additionally now not talk about the affected person’s statistics with others, together with family members, without proper authorization from the pupil.

pupil fitness statistics are retained in the medical records department for a complete of seven years (apart from current 12 months from date of ultimate entry), after which period the information might be destroyed.

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