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Test Number : AHIMA-CCS
Test Name : Certified Coding Specialist
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%)
Tasks:
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%)
Tasks:
Diagnosis:
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
Procedure:
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%)
Tasks:
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%)
Tasks:
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%)
Tasks:
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%)
Tasks:
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%)
Tasks:
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%)
Tasks:
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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Medical Coding answers

How hospitals can enhanced manipulate documentation and preserve income amid the pandemic | AHIMA-CCS PDF get and test dumps

in collaboration with 3M fitness information techniques - Tuesday, January 19th, 2021 Print  | electronic mail

Liz Guyton currently grew to be the director of the 3M health counsel methods division for the U.S. and Canada, a task she earned with years of journey managing healthcare reimbursement, revenue cycle, provide chain and IT engagement.

With a history in finance, Ms. Guyton was drawn to the healthcare sector early in her profession after working as an accounting manager for a small health center. In that function, she noticed how advisable the adjustments she made in the finance department may be for the medical institution as a whole.

She joined 3M HIS in 2016, running its healthcare consulting follow in Atlanta. She believes the company is a valuable associate to hospitals, helping corporations achieve accurate healthcare documentation while cutting back the work integral to keep profits ranges.

"we are the one provider with an built-in platform that helps businesses from the second the general practitioner is having that conversation — first talking that documentation into existence — all the option to auditing the codes onto a ultimate bill," she noted.

below, Ms. Guyton discusses how 3M HIS is assisting hospitals amid the pandemic, peculiarly as they take on the shift to digital operations.

word: Responses were edited for length and readability.

question: A exact-of-mind theme today amongst healthcare executives is the shift to virtual. What are some of the techniques 3M has been in a position to pivot to a digital environment?

Liz Guyton: There are no different organizations as without delay impacted by using the pandemic as hospitals. When the pandemic began, they begun getting a lot of requests and questions about documentation and coding. what is the right code to use for the diverse features that they at the moment are rendering with COVID-19? How do they make certain that they document this appropriately?

Our team felt this sort of responsibility to be sure that their consumers had the relevant suggestions. They quickly launched a series of COVID-focused webinars to aid answer these questions for their shoppers. Webinars have all the time been a fine approach for us to connect with their purchasers and to support lead and show on coding adjustments and scientific documentation top-rated practices, however there changed into just this groundswell of wanting COVID coding information and schooling. more than 10,000 people dialed in to the primary classes. They needed to then add, as which you can think about, additional  sessions, so people might ask questions, get solutions and believe at ease in regards to the COVID ICD-10 codes.

past the growing to be digital connection to consumers for in-the-second education, they needed to handle how we’d play host to their annual customer experience Summit, their summer season users’ community assembly. because the pandemic unfold, they made the complicated however quintessential choice to shift it from an in-grownup adventure in Salt Lake metropolis to be an entirely digital event. an awful lot of what their teams and their shoppers love in regards to the experience has all the time been the personal connection and engagements, and the capacity for their consumers to speak one-one-one with us and each other, benefit insights, optimal product practices and establish enhancements.

despite the challenges of pivoting to a virtual adventure, their 2020 customer journey Summit became incredibly a hit. They had nearly 2,000 people attend, more than we’ve ever had. via all of it, their purchasers had been capable of well-nigh join with us and with every different, earn carrying on with education credit (up greater than 160 p.c from 2019), and share their competencies and journey, just in a special format than general. 

Q: As you work with healthcare organizations around the U.S. and globe, what are they expressing as their greatest needs in a virtual atmosphere?

LG: Their valued clientele face savings in profits and definitely have had an increase in fees, so that they're challenged. They’re dealing with a requirement for staff, and filling gaps on the fly for his or her profits cycle. In clinical documentation, lots of those gaps are sometimes being stuffed by means of nurses. They've had body of workers individuals who had been sick and not working. They've had people who are taking care of people who are ill and not working. So, the gaps are very actual.

consumers also need to work out how they can meet their existing goals and objectives for coding and scientific documentation in a way that streamlines individuals and approaches, and charges less cash. Their most instant need is staffing to fill their construction needs for coding and medical documentation. there is additionally the query “How do they get the earnings up and the prices down?,” which is always a clinic’s challenge, pandemic or no.

Q: How has 3M HIS partnered with organizations to aid in their success throughout these complicated instances?

LG: One selected customer in big apple obligatory to stand up a health center inside a week of COVID first hitting that enviornment. Their coders had to have a device in region to code the services that have been being given. They partnered with them to remotely get their technology, 3M™ 360 embody™, are living and ready for them to serve their sufferers promptly. It changed into an all-palms-on-deck effort for their team to make it take place enormously speedy and they are proud to had been in a position to successfully launch their expertise to help this client after they mandatory it most. 

beyond the immediacy of launching technology for brief hospitals, we’ve had shoppers tell us they must suppose of a special approach to carry medical documentation, and ask 3M HIS “Will you tackle the total manner of medical documentation for us, use your personal team of workers, use your personal system after which just carry to us the final work product?” 

now they have been in a position to work closely with valued clientele with the intention to absolutely outsource their complete  scientific documentation integrity department to us. They address that for them, which in flip potential they and their leadership can focal point on other things whereas they bring the outcomes to them. Their purchasers are loving this mannequin, especially now, and that they don't intend to ever go lower back. 

additionally, clinical documentation integrity teams every so often have needed to flow back to the bedside to assist as crucial. 3M HIS helps businesses insert technology in a way that reduces that labor burden. In clinical documentation, lots of the work historically has happened submit documentation, when the health care professional has achieved their observe, then CDI will overview for documentation gaps and find, "Oh, I deserve to get this. I need to ask the healthcare professional this query." 

Our know-how uses synthetic intelligence that reasons across files as smartly as the complete affected person come upon in real time, and so many  of those inquiries to the surgeon then occur throughout the time of their documentation, getting rid of the administrative burden for them of having to revisit and clarify documentation so late within the patient care experience. this is crucial now not only for income cycle ambitions, however vital for the accuracy of affected person suggestions, helping greater clinical care and continuity of services. 

We call these documentation clarifications, nudges, where they offer the nudge to the surgeon at the aspect of documentation. They name it a nudge as adversarial to an edit as a result of none of us like to get these little pop-up issues that cease us from doing their work. Physicians can respond to them if they want to. They desire that they do, but if they don't, it would not cease their work. 

A fresh pattern analysis from an tutorial clinical core client that makes use of their nudging ideas shows brilliant effects. This customer desired to take the concept slow, so it begun with five nudges in line with the most usual CDI backend queries like coronary heart failure and pneumonia diagnoses, and kidney disease specificity. In a pattern of most effective 1,000 accounts, these 5 clinical thought nudges gained their client an estimated quarter of 1,000,000 dollars in salary.

For a different health gadget client, health practitioner steps to finished initiatives, measured in clicks, went from seven to three – an incredible time savings. CDI consumer clicks went down from 19 to 5, which is wonderful. An orthopedic surgeon pointed out, "I are not looking for working towards. i'm already the use of it. or not it's so handy." those tools have been capable of cut back the burden on the caregiver and automatically create extra time to spend with the affected person. 

I share these examples to demonstrate how 3M HIS meets purchasers the place they are of their documentation and coding journeys, and how vital it's for us, especially within the pandemic when virtual connections are of utmost value. it is all the time their goal to provide consumers a direction from trap to code, with demonstrable consequences and successes along the style.

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