In addition to clinical knowledge, CDI Specialists require knowledge of the coding systems to ensure their documentation improvement efforts are consistent with the guidelines and conventions which govern accurate and complete coding. One way to assure this knowledge is by earning the CCS coding credential, offered by AHIMA, which demonstrates mastery-level coding skills, generally in a hospital setting.
The CCS Exam Review: CCS for CDI prepares candidates for the current (2018) CCS Exam. (The AHIMA CCS exam will update to the 2019 codes and guidelines on May 1, 2019.)
The CCS Exam Review: CCS for CDI offers a comprehensive review of materials covered on the exam including:
- ICD-10-CM/PCS, CPT, and HCPCS Level II coding and guidelines
- Reimbursement methodologies including the Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS)
- Health information documentation requirements
- Regulatory guidelines and reporting requirements for inpatient and outpatient services
- Data quality management
- Information technology and security
- Privacy, confidentiality, legal and ethical issues
- Compliance review
Knowledge checks, assessment exercises, and a CCS Readiness Assessment offer over 250 practice questions with rationale to ensure mastery of material.
A bonus study guide helps you set-up an organized study schedule.
The CCS Exam Review: CCS for CDI covers:
- Selecting and appropriately sequencing the diagnoses and procedures that require coding according to current coding and reporting requirements using the official ICD-10-CM/PCS coding guidelines for acute care (inpatient) visits and the official ICD-10-CM and the official CPT/HCPCS Level II coding guidelines for hospital outpatient services.
- Selecting the principal diagnosis, principal procedure, complications, comorbid conditions, and other diagnoses and procedures that require coding according to UHDDS definitions and Coding Clinic.
- Selecting the reason for encounter, pertinent secondary conditions, primary procedure, and other procedures that require coding according to UHDDS definitions, CPT Assistant, Coding Clinic, and HCPCS.
- Assigning the present on admission (POA) indicators.
- Evaluating and verifying the impact of code selection on Diagnosis Related Group (DRG) assignment based on Inpatient Prospective Payment System (IPPS) definitions and Outpatient Prospective Payment System (OPPS) reporting requirements.
- Assigning and validating the discharge disposition.
- Applying OPPS reporting requirements related to modifiers, CPT/HCPCS Level II, medical necessity, and Evaluation and Management code assignment (facility reporting).
- Applying clinical laboratory service requirements.
- Assessing the quality of coded and abstracted data. Ensuring coding and auditing is current and accurate. Resolving coding edits such as: CCI, MCE, and OCE.
- Interpreting medical record documentation, consulting with physicians about documentation, querying, reference materials, and posting charges.
- Navigating through the EHR, and accurate and efficient use of coding, grouping, and data analytic software.
- Ensuring confidentiality and security of patient information. Applying ethical coding standards.
- Evaluating accuracy and completeness of the medical record according to organizational policy and external regulations and standards. Monitoring and reporting compliance concerns.