CCS-P Study Set TEST BANK QUESTIONS AND
ACCURATE DETAILED ANSWERS \VERIFIED 100%
LATEST VERSION 2025 -2026
AHIMA defines as the use of computer software that
automatically generates a set of medical codes for
CAC- computer assisted
review , validation, and use based upon the
coding
documentation provided by the various providers of
healthcare.
modifier: A1-principle required for patients covered by Medicare when
physical of record reporting Initial Hospital Service codes
Organized by problem number
Database: history and physical
Problem List: titles, numbers, dates of
problems..."Table of Contents" of the record
POMR- PROBLEM
ORIENTED MEDICAL Initial Plan: describes diagnostic, therapeutic, and
RECORD 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
formulary for drugs
Cost Sharing Provision of
co-pay
Health Ins.
benefit limitations
, forceps or vacuum extractor delivery without mention
of indication
Common Complication of
renal sphincter tear, not associated with 3rd degree
Labor and Delivery
peritoneal laceration
trauma to perineum and vulva during delivery
HIPAA law in regards to defers to state law on matters that concern minors
children under 18
disease index list diagnostic codes in order
physician index lists cases in order by physician name or number
cross reference patient name and medical record
master patient index
number
operation index list medical records by operative procedures
when clinical documentation is entered in computer at
Point of Care Service
the same time and location of service
published by CMS. Contains both proposed and final
Federal Register
notes for Conditions of Participation for hospitals
Books fault> Doctor has detail documented, book
NEC
does not contain matching detail
Doctors fault> Doctor lacks specific documentation
NOS
although ICD has detailed options
supplemental classification
Problem based include: need for vaccine
V codes
Fact based include: history of, outcome of delivery
Service based: dialysis, chemo, therapy
When is an interval H&P when a patient is readmitted for the same or related
permitted problem with-in 30 days
physical findings
Required data for Acute
lab and diagnostic test results
Care and ER records
follow-up instructions
ACCURATE DETAILED ANSWERS \VERIFIED 100%
LATEST VERSION 2025 -2026
AHIMA defines as the use of computer software that
automatically generates a set of medical codes for
CAC- computer assisted
review , validation, and use based upon the
coding
documentation provided by the various providers of
healthcare.
modifier: A1-principle required for patients covered by Medicare when
physical of record reporting Initial Hospital Service codes
Organized by problem number
Database: history and physical
Problem List: titles, numbers, dates of
problems..."Table of Contents" of the record
POMR- PROBLEM
ORIENTED MEDICAL Initial Plan: describes diagnostic, therapeutic, and
RECORD 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
formulary for drugs
Cost Sharing Provision of
co-pay
Health Ins.
benefit limitations
, forceps or vacuum extractor delivery without mention
of indication
Common Complication of
renal sphincter tear, not associated with 3rd degree
Labor and Delivery
peritoneal laceration
trauma to perineum and vulva during delivery
HIPAA law in regards to defers to state law on matters that concern minors
children under 18
disease index list diagnostic codes in order
physician index lists cases in order by physician name or number
cross reference patient name and medical record
master patient index
number
operation index list medical records by operative procedures
when clinical documentation is entered in computer at
Point of Care Service
the same time and location of service
published by CMS. Contains both proposed and final
Federal Register
notes for Conditions of Participation for hospitals
Books fault> Doctor has detail documented, book
NEC
does not contain matching detail
Doctors fault> Doctor lacks specific documentation
NOS
although ICD has detailed options
supplemental classification
Problem based include: need for vaccine
V codes
Fact based include: history of, outcome of delivery
Service based: dialysis, chemo, therapy
When is an interval H&P when a patient is readmitted for the same or related
permitted problem with-in 30 days
physical findings
Required data for Acute
lab and diagnostic test results
Care and ER records
follow-up instructions
