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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 exam Format | AHIMA-CCS Course Contents | AHIMA-CCS Course Outline | AHIMA-CCS exam Syllabus | AHIMA-CCS exam 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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Oportunidades de Negocio

Canalizar peticiones de oferta por parte de clientes a las empresas TIC.

Negociación conjunta

Acuerdos grupales con proveedores de forma que logremos una mayor capacidad de ahorro.

NETWORKING

Fomentar el conocimiento y colaboración entre los agentes del sector y los sectores clientes.

OBJETIVOS ABETIC

Para el desarrollo de sus fines u objetivos, la Asociación tiene las siguientes funciones

 

Garantías

Ofrecer a los clientes y, en general, a terceras personas, las garantías morales y técnicas inherentes a su condición de miembro de la Asociación, de acuerdo con el Código Deontológico que pudiera establecerse en el seno de la misma

Promoción

Cualquier actividad o actuación tendente a mejorar, promover, potenciar, difundir y dignificar la actividad profesional relacionada con la prestación de servicios de desarrollo, implantación e instalación de nuevas tecnologías de la información y de la comunicación (TIC), en la provincia de Burgos

h
Profesionalización

Contribuir al progreso de la profesión y a la defensa de los intereses de sus afiliados, mediante la negociación colectiva, planteamiento de conflictos colectivos, diálogo social, participación institucional en los organismos públicos de las Administraciones laborales, etc., siempre de conformidad con los acuerdos de las organizaciones patronales o empresariales a las que pertenezcan los miembros asociados

h
Implantación TIC

Dinamizar, fomentar y promocionar la demanda e implantación de productos y servicios relacionados con las nuevas tecnologías en nuestro entorno socio-económico

Intrusismo

Denunciar el intrusismo y las malas prácticas

Colaboraciones

Establecer, mantener y fomentar contactos y colaboraciones con las entidades provinciales, territoriales, nacionales y extranjeras de análoga naturaleza y finalidad, facilitando a las empresas similares relaciones

Aunando esfuerzos

Aunar esfuerzos en defensa de la calidad de los productos y servicios elaborados o prestados por sus miembros

Defensa de intereses

El estudio y la defensa de los intereses económicos, comerciales, tecnológicos e industriales del sector en general y, en particular, de las empresas a las que representa directamente

Representación

La representación, gestión, defensa y fomento de los intereses de sus miembros frente a los diferente órganos de la Administración Pública en general, incluida la vía judicial o frente a cualquier institución o persona pública o privada

Defendiendo los intereses de las empresas TIC

ABETIC es la organización profesional/empresarial constituida por la libre asociación de empresarios y/o empresas cuyo objeto social principal sea la prestación de servicios de desarrollo, implantación e instalación de nuevas tecnologías de la información y de la comunicación, principalmente relacionadas con la informática, Internet y comunicaciones vía satélite o similares, en el ámbito territorial de la provincia de Burgos

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