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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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Medical Specialist learning

school of Nursing items far flung simulation discovering at Indiana convention | AHIMA-CCS Real exam Questions and exam dumps

The Boise State tuition faculty of Nursing simulation group lately offered an innovative distance discovering approach for simulations at the SimGHOSTS conference in citadel Wayne, Indiana.

A simulation state of affairs permits students to count on the nursing position and take care of patients in a realistic atmosphere. Simulations involve patients who can be mannikins or employed actors mimicking certain clinical concerns, and students are in a position to determine the affected person, provide care, and make medical decisions. Then, faculty are in a position to take a look at and supply comments on pupil performance. Simulation has been a part of nursing schooling for a long time, but it has grown and developed in exciting new techniques over the past two many years. Simulation gives students with a low-possibility but particularly realistic atmosphere to follow vital thinking skills. historically, most simulation has been completed in-grownup. remaining 12 months, COVID-19 response measures moved universities online around the world, and the Boise State simulation team came collectively to convey on-line simulations as near fact as feasible.

The team developed a number of methods that could sound prevalent to any person who’s performed a video online game before. These blanketed screen-primarily based simulations where students are introduced with a situation and choose moves from a menu, observing recorded simulation scenarios after which discussing with a school member, or a select-your-personal-adventure-fashion recorded simulation where students select what occurs next and then acquire remarks on their choices. Kelley Connor, affiliate professor and director of simulated getting to know and analysis, reports the applications of expertise in nursing training. “online game-based mostly getting to know options allow college students to make decisions and notice the results of those selections. they can additionally re-do the simulation diverse times to discover what happens when distinctive choices are made.” Says Connor. despite the fact, these distinct-option-fashion simulations aren’t really reflective of medical experiences. “a problem with reveal-based simulation is that the decisions college students must select from have been created for them. college students comprehend the answer is in entrance of them, they simply need to locate it.”

with the intention to create a remote simulation journey that is closer to the real issue, the Boise State simulation group has developed what they name ‘puppet’ simulations, where college students tune in to a live simulation from home. students tackle the position of the nurse and that they supply instructions to a personnel or school member performing in their location. Simulations are held in small mock-hospital rooms, and just one to 2 masked people are accepted in the room to enable for physical distancing. college students must make choices and supply their ‘puppet’ guidance to perform, comparable to asking questions about medical heritage or inspecting a wound dressing. they are making the entire same choices and having the entire equal conversations they might have in the event that they were actually within the room with their patient.

Image is divided into four quarters. Quarter one: a nurse taking a mannequin's blood pressure, with the blood pressure value displayed for the viewer in the upper right corner. Quarter 2: A nurse applies personal protective equipment from a cart in a hospital hallway. Quarter 3: A nurse takes notes in a notebook and sits across a table from a patient in a consultation room. Quarter 4: A nurse adjusts bedding for a mannequin patient. college students can tune in to several remark cameras for a whole lot of scenarios, together with recording a must-have signals (suitable left), the use of own protective equipment (desirable right), consulting with irritable or manic patients (backside left) and assisting patients with remedy (backside right).

“i would receive an guide to clean my hands once I entered the room, and the pupil would make smalltalk with the patient meanwhile.” Says Angela George, simulation operations professional and more these days, faraway simulation puppet. “It’s decent practice to ask a affected person permission before touching them, and inform them what you should achieve this they be mindful. You don’t get that type of interaction in a video online game, and it’s a crucial a part of offering constructive care.”

As always, students are required to finished technical advantage laboratory classes, where they learn how to insert IV traces, gown wounds, and different integral nursing abilities. These classes are held in massive lecture rooms with increased air circulate and space for physical distancing according to Boise State COVID-19 instructions. currently, simulations are being held in-person on Boise State campus. despite the fact, the simulation team is prepared to deliver lower back online simulations and live distance simulations as an everyday a part of coursework if crucial.


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