CCS-P Exam Guide with Questions and
Answers/100% Correct/ Grade A+
According to AMA medical decision making is measured by - ✔✔1. number of dx or
management options
2. amount and complexity of data review
3. risk of complications
CPT Assistant - ✔✔provides official guidance in CPT coding
published by the AMA
A barrier to wide spread use of automated code assignments is - ✔✔poor quality of
documentation
When should coders assign codes from lab reports alone - ✔✔Never. If findings are out of
normal range and the physician has ordered additional testing or treatment; consult with the
physician as to whether the Dx should be added or if an abnormal finding should be listed.
4 cooperating parties of ICD-9 and responsibilities of each - ✔✔NCHS (national center for
health statistics): maintaines dx classifications in Vol 1&2
,CMS: maintains procedural classification in Vol 3
AHIMA & AHA: give advice & assistance on coding guidelines in conjunction with health
information management practitioners, physicians, & other users of ICD-9
When can code 99291 (E/M critical care) be used in place of a medical visit or ER code -
✔✔When the patient meets the definition of critical care and receives outpatient care on the
same day
limiting charge - ✔✔this is the amount a NON PAR Medicare provider can collect from a
patient in excess of 15% over the NON PAR Medicare approved amount.
When does CMS send the payment directly to the patient - ✔✔when a NON PAR provider
does not accept assignment
hard coding - ✔✔refers to CPT/HCPCS codes that appear in the hospitals chargemaster and
will be included automatically on the patient's bill.
CAC- computer assisted coding - ✔✔AHIMA defines as the use of computer software that
automatically generates a set of medical codes for review , validation, and use based upon the
documentation provided by the various providers of healthcare.
, modifier: A1-principle physical of record - ✔✔required for patients covered by Medicare
when reporting Initial Hospital Service codes
POMR- PROBLEM ORIENTED MEDICAL RECORD - ✔✔Organized by problem number
Database: history and physical
Problem List: titles, numbers, dates of problems..."Table of Contents" of the record
Initial Plan: describes diagnostic, therapeutic, and patient education plans
Progress Note: documents the progress of a patient throughout the episode of care
Discharge Note/ Transfer Note: summarizes episode of care and current status of patient
Cost Sharing Provision of Health Ins. - ✔✔formulary for drugs
co-pay
benefit limitations
Answers/100% Correct/ Grade A+
According to AMA medical decision making is measured by - ✔✔1. number of dx or
management options
2. amount and complexity of data review
3. risk of complications
CPT Assistant - ✔✔provides official guidance in CPT coding
published by the AMA
A barrier to wide spread use of automated code assignments is - ✔✔poor quality of
documentation
When should coders assign codes from lab reports alone - ✔✔Never. If findings are out of
normal range and the physician has ordered additional testing or treatment; consult with the
physician as to whether the Dx should be added or if an abnormal finding should be listed.
4 cooperating parties of ICD-9 and responsibilities of each - ✔✔NCHS (national center for
health statistics): maintaines dx classifications in Vol 1&2
,CMS: maintains procedural classification in Vol 3
AHIMA & AHA: give advice & assistance on coding guidelines in conjunction with health
information management practitioners, physicians, & other users of ICD-9
When can code 99291 (E/M critical care) be used in place of a medical visit or ER code -
✔✔When the patient meets the definition of critical care and receives outpatient care on the
same day
limiting charge - ✔✔this is the amount a NON PAR Medicare provider can collect from a
patient in excess of 15% over the NON PAR Medicare approved amount.
When does CMS send the payment directly to the patient - ✔✔when a NON PAR provider
does not accept assignment
hard coding - ✔✔refers to CPT/HCPCS codes that appear in the hospitals chargemaster and
will be included automatically on the patient's bill.
CAC- computer assisted coding - ✔✔AHIMA defines as the use of computer software that
automatically generates a set of medical codes for review , validation, and use based upon the
documentation provided by the various providers of healthcare.
, modifier: A1-principle physical of record - ✔✔required for patients covered by Medicare
when reporting Initial Hospital Service codes
POMR- PROBLEM ORIENTED MEDICAL RECORD - ✔✔Organized by problem number
Database: history and physical
Problem List: titles, numbers, dates of problems..."Table of Contents" of the record
Initial Plan: describes diagnostic, therapeutic, and patient education plans
Progress Note: documents the progress of a patient throughout the episode of care
Discharge Note/ Transfer Note: summarizes episode of care and current status of patient
Cost Sharing Provision of Health Ins. - ✔✔formulary for drugs
co-pay
benefit limitations
