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Competencies Coding Exams
Health Care Information Programs

Updated 9/13/09

AMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION (AHIMA)
Certified Coding Specialist (CCS)
Certified Coding Specialist -Physician's Office (CCS-P)

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 CCA exam has 100 multiple choice questions and lasts 2 hours.
* The CCS exam is in two parts.  Part 1 has 60 multiple choice questions and lasts 1 hour.  Part 2 consists of 13 cases to code and lasts 3 hours.
* The CCS-P exam is in two parts.  Part 1has 60 multiple choice questions and lasts 1 hour.  Part 2 consists of 16 cases to code and lasts 2 hours.

The exams are based on the following domains.  Go to http://www.ahima.org/certification/ for additional information.


DOMAINS AND TASKS
CERTIFIED CODING SPECIALIST (CCS) EXAMINATION

Domain 1: Health Information Documentation
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
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
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
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
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
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
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
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
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.

DOMAINS AND TASKS
CERTIFIED CODING SPECIALIST – PHYSICIAN’S OFFICE BASED

 Domain 1: Health Information Documentation
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 
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
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
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

DOMAINS AND TASKS
CERTIFIED CODING ASSOCIATE

CERTIFIED CODING ASSOCIATE (CCA) COMPETENCY STATEMENTS - AHIMA

Domain 1: Health Records and Data Content

  1. Collect and maintain health data.
  2. Analyze health records to ensure that documentation supports the patient’s diagnosis and procedures, reflects progress, clinical findings and discharge status.
  3. Request patient specific documentation from other sources (such as ancillary departments, physicians office, and the like).
  4. Apply clinical vocabularies and terminologies used in the organization’s health information systems.

Domain 2: Health Information Requirements and Standards

  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 guidelines
  3. Report compliance findings according to organizational policy.
  4. Assist in preparing the organization for accreditation, licensing and/or certification surveys.

Domain 3: Clinical Classification Systems

  1. Utilize electronic applications to support clinical classification and coding (such as encoders).
  2. Assign secondary diagnosis procedure codes using ICD-9-CM official coding guidelines.
    1. Assign principle diagnosis (Inpatient) to first lined diagnosis (Outpatient).
    2. Assign secondary diagnosis(es), including complications and comorbidities (CC).
    3. Assign principal and secondary procedure(s).
  3. Assign procedure codes using CPT coding guidelines.
  4. Assign appropriate HCPCS codes.
  5. Identify discrepancies between coded data and supporting documentation.
  6. Consult reference materials to facilitate code assignment.

Domain 4: Reimbursement Methodologies

  1. Validate the data collected for appropriate reimbursement.
    1. Validate Diagnosis Related Groups (DRGs).
    2. Validate Ambulatory Payment Classifications (APCs).
  2. Comply with the National Correct Coding Initiative.
  3. Verify the National and Local Coverage Determinations (NCD/LCD) for medical necessity.

Domain 5: Information and Communication Technologies

  1. Use a personal computer to ensure data collection, storage, analysis and reporting of information.
  2. Use common software applications (such as word processing, spreadsheets, e-mail, and the like) in the execution of work processes.
  3. Use specialized software in the completion of HIM processes.

Domain 6: Privacy, Confidentiality, Legal, and Ethical Issues

  1. Apply policies and procedures for access and disclosure of personal health information.
  2. Release patient-specific data to authorized individuals.
  3. Apply ethical standards of practice.
  4. Recognize and report privacy issues/problems.
  5. Protect data integrity and validity using software or hardware technology.

REQUIRED CONTINUING EDUCATION TO RETAIN CODING CREDENTIALS

After successful completion of the certification examination certified coders must complete required continuing education to retain their credentials.  The purpose is to encourage life-long learning and maintain professional competence. The Program faculty will review these requirements in more detail with you. If you do not fulfill these AHIMA requirements, you will loose your credential and will no longer be certified.

Continuing education activities include attendance at seminars, journal reading, additional college course work, and other educational activities.  These must be reported to AHIMA on required forms along with payment of a CE assessment fee.  Go to www.ahima.org/recertification for additional information.

AMERICAN ACADEMY OF PROFESSIONAL CODERS (AAPC)

The American Academy of Professional Coders (AAPC) provides certified credentials to medical coders in physician offices, hospital outpatient facilities, ambulatory surgical centers and in payer organizations. CPC, CPC-H, CPC-P, and CIRCC are the certifications they offer for outpatient medical coding.  The following information is taken from their website at www.aapc.com.

Certified Professional Coder (CPC)

Demonstrates a broad encompassing knowledge and expertise in reviewing and assigning the correct coding of physician services, procedures and diagnosis for medical claims. It validates an individual's ability to assign codes based on national coding guidelines and operative reports, comprehend medical terminology and human anatomy and apply billing reimbursement guidelines. The CPC examination consists of questions regarding the correct application of CPT, HCPCS Level II procedure and supply codes and ICD-9-CM diagnosis codes used for billing professional medical services to insurance companies.   Take CPC exam if you code in the following places or situations:

  1. Physician office or group
  2. Hospital-associated physician office or group
  3. Health system-associated physician office or group
  4. Home health agency
  5. Physician group at University and or in teaching setting
  6. Compliance auditor or forensic auditor of physician claims
  7. Physician Billing service
  8. Ambulatory surgery center (ASC)
  9. Outpatient hospital services not reimbursed by Ambulatory Patient Category (APCs) groups

Certified Professional Coder – Outpatient Hospital (CPC-H)

The CPC-H credential validates proficiency in accurately coding outpatient facility/hospital services. The examination consists of questions regarding the correct application of CPT, HCPCS Level II procedure and supply codes and ICD-9-CM diagnosis codes used for coding and billing outpatient facility services to insurance companies. Take CPC-H exam if you code in the following places or situations:

  1. Billing Ambulatory Patient Category groups (APCs) for facility outpatient services.
  2. Working in hospital outpatient billing and coding department
  3. Auditing facility outpatient service billing and coding
  4. Ambulatory Surgical Center
  5. Performing utilization review for outpatient services

Certified Professional Coder – Payer (CPC-P)

The CPC-P credential concentrates on coding and billing after it’s been submitted to the payer. The CPC-P certification exam will test the examinee’s basic knowledge of coding-related payer functions with emphasis on how those functions differ from provider coding. The relationship between coding and payment functions will be explored in depth. Those who pass this exam validate their aptitude, proficiency, and knowledge within the payer environment.  Take CPC-P exam if you code in the following places or situations:

  1. Claims manager for a payer (private insurance, Medicare, Medicaid, etc.)
  2. Auditor for a payer
  3. Utilization review
  4. Post-billing auditor for a physician group or facility
  5. Billing service

Certified Interventional Radiology Cardiovascular Coder (CIRCC)

The CIRCC (Certified Interventional Radiology Cardiovascular Coder) credential was created for individuals who are working in the complex and specialized areas of interventional radiology and cardiovascular coding and charging. The exam covers diagnostic angiography, non-vascular interventions, percutaneous vascular interventions, diagnostic cardiac catheterization and basic coronary arterial interventions as well as ICD-9-CM, basic coding (E&M, modifiers, etc.), anatomy and terminology. Those who pass this exam validate this additional level of education, knowledge and expertise required in this complex and specialized arena.

Specialty Credentials

The AAPC has developed specialty credentials to enable working coders to demonstrate superior levels of expertise in selected specialty disciplines. Whether a coder wishes to show expertise in a specialty they currently work in or wish to move to another specialty these credentials are designed to prove superior knowledge and skills. Exams aptly measure preparedness for “real world” coding by being operative/patient-note based. Those who pass this exam demonstrate their coding expertise in a specialty with unique coding, reimbursement, and compliance challenges.