The American Health Information Management Association offers each exam in locations throughout the nation.  The Certified Coding Specialist (CCS) exam focuses on inpatient acute care diagnosis and procedural coding and hospital outpatient procedural coding (ICD-9-CM and CPT).  The Certified Coding Specialist - Physician's Office (CCS-P) focuses on clinic outpatient ICD-9-CM diagnostic and CPT procedural coding. 

The CCS exam consists of four-option, multiple-choice questions written at three different cognitive levels: recall, application, and analysis. The exam is based on the following domains.  The percentage of test questions is located in parentheses at the end of each domain.

DOMAINS AND TASKS
CERTIFIED CODING SPECIALIST (CCS) EXAMINATION

Domain 1: Health Information Documentation (15%) 
1.         Interpret health record documentation using knowledge of anatomy, physiology, clinical 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 providers to obtain further clinical documentation to assist with code assignment.
4.         Consult reference materials to facilitate code assignment.
5.         Identify patient encounter type.
6.         Identify and post charges for healthcare services based on documentation

Domain 2: Diagnosis Coding (20%) 
1.         Select the diagnoses that require coding according to current coding and reporting requirements for acute care (inpatient) services.
2.         Select the diagnoses that require coding according to current coding and reporting requirements for outpatient services.
3.         Interpret conventions, formats, instructional notations, tables, and definitions of the classification system to select diagnoses, conditions, problems, or other reasons for 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-9-CM coding guidelines.

Domain 3: Procedure Coding (20%)
1.         Select the procedures that require coding according to current coding and reporting requirements for acute care (inpatient) services.
2.         Select the procedures that require coding according to current coding and reporting requirements for outpatient services.
3.         Interpret conventions, formats, instructional notations, and definitions of the classification system and/or nomenclature to select procedures/services that 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-9-CM coding guidelines.
6.         Apply the official CPT/HCPCS Level II coding guidelines.

Domain 4: Regulatory Guidelines and Reporting Requirements for Acute Care (Inpatient) Service (10%)
1.         Select the principal diagnosis, principal procedure, complications, comorbid conditions, other diagnoses and procedures that require coding according to UHDDS definitions and Coding Clinic for ICD-9-CM.
2.         Evaluate the impact of code selection on Diagnosis Related Group (DRG) assignment.
3.         Verify DRG assignment based on Inpatient Prospective Payment System (IPPS) definitions.
4.         Assign the appropriate discharge disposition.

Domain: 5: Regulatory Guidelines and Reporting Requirements for Outpatient Services (10%)
1.         Select the reason for encounter, pertinent secondary conditions, primary procedure, and other procedures that require coding according to UHDDS definitions, CPT Assistant, Coding Clinic for ICD-9-CM, 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)

Domain 6: Data Quality and Management (8%)
1.         Assess the quality of coded data.
2.         Educate healthcare providers regarding reimbursement methodologies, documentation rules, and regulations related to coding.
3.         Analyze health record documentation for quality and completeness of coding.
4.         Review the accuracy of abstracted data elements for data base 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 7: Information and Communication Technologies (5%)
1.         Use PC to ensure data collection, storage, analysis, and reporting of information.
2.         Use common software applications (for example, word processing, spreadsheets, and e-mail) in the execution of work processes.
3.         Use specialized software in the completion of HIM processes.

Domain 8: Privacy, Confidentiality, Legal, and Ethical Issues (6%)
1.         Apply policies and procedures for access and disclosure of personal health information.
2.         Apply AHIMA Code of Ethics/Standards of Ethical Coding
3.         Recognize/report privacy issues/problems.
4.         Protect data integrity and validity using software or hardware technology.

Domain 9: Compliance (6%)
1.         Participate in the development of institutional coding policies to ensure compliance with official coding rules and guidelines.
2.         Evaluate the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards.
3.         Monitor compliance with organization-wide health record documentation and coding guidelines.
4.         Recognize/report compliance concerns/findings.

CERTIFIED CODING SPECIALIST – PHYSICIAN’S OFFICE BASED

 Domain 1: Health Information Documentation (17%)
1.         Interpret health record documentation to identify diagnoses and conditions for code assignment.
2.         Interpret health record documentation to identify procedures or services for code assignment
3.         Determine if sufficient clinical information is available to assign one or more diagnosis codes
4.         Determine if sufficient clinical information is available to assign one or more procedure or service codes
5.         Consult with physicians or other healthcare providers when additional information is needed for coding and/or to clarify conflicting or ambiguous information
6.         Consult reference materials to facilitate code assignment
7.         Identify the etiology and manifestation(s) of clinical conditions 

Domain 2: Coding (42%)
1.         Assign ICD-9-CM code by applying “Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office)”
2.         Interpret ICD-9-CM conventions, formats, instructional notations, tables, and definitions to select diagnoses, conditions, problems, or other reasons for the encounter that require coding
3.         Interpret CPT and HCPCS II guidelines, format, and instructional notes to select services, procedures, and supplies that require coding
4.         Assign CPT code(s) for procedures and/or services rendered during the encounter
5.         Assign codes to identify Evaluation and Management (E/M) services
6.         Recognize if an unlisted code must be assigned
7.         Exclude from coding those procedures that are component parts of another reported procedure code
8.         Code for the professional vs. technical component when applicable
9.         Assign HCPCS II codes
10.       Append modifiers to procedure or service codes when applicable

Domain 3: Reimbursement Methods and Regulatory Guidelines (20%)
1.         Apply global surgical package concept to surgical procedures
2.         Apply bundling and unbundling guidelines (for example, National Correct Coding Initiative [NCCI])
3.         Interpret health record documentation to identify diagnoses and conditions for code assignment
4.         Apply reimbursement methods for billing or reporting (for example, OIG, CMS (HCFA), Federal Register)
5.         Link diagnosis code to the associated procedure code for billing or reporting
6.         Evaluate payer remittance or payment (for example, EOB, EOMB) reports for reimbursement and/or denials
7.         Interpret Local Medical Review Policies (LMRP) or payer policies to determine coverage
8.         Process claim denials and/or appeals 

Domain 4: Data Quality (21%)
1.         Validate assigned diagnosis and procedure codes supported by health record documentation
2.         Validate assigned Evaluation and Management codes based on health record documentation using the E/M guidelines
3.         Assess the quality of coding and billing using routinely generated reports
4.         Verify that the data on the claim form correctly reflect the services provided
5.         Verify that the data on the claim form correctly reflect the conditions managed or treated during the encounter
6.         Validate the accuracy of the required data elements on the claim form
7.         Conduct coding and billing audits for compliance and trending
8.         Determine educational needs for physicians and staff on reimbursement and documentation rules and regulations related to coding
9.         Participate in the development of coding and billing policies and procedures for reporting professional services
10.       Evaluate payer remittance or payment (for example, EOB, EOMB) reports for data quality