CODING KNOWLEDGE & SKILLS: CCS EXAM
PREP
Why is it important for all coding professionals to adhere to the same coding rules and conventions
when assigning ICD-10-CM and CPT codes?
Consistency in data. Coded data are reviewed not only for reimbursement purposes, but for researchers
to track public health and for the government to measure quality and safety practices. These data are
collected for present and future use. However, in order for the data to be reliable and accurate, the
same coding rules and conventions need to be followed by everyone. When coders allow
reimbursement to inappropriately influence code assignment, they could potentially be putting their
physician or entity at risk for audits, fines and negative publicity.
Discuss when a symptom should be reported.
Symptoms are reported when a definitive diagnosis is not made by the provider. Example: If the
documentation only states that the patient presents with a cough and fever, codes for the cough and
fever should be reported. When a definitive diagnosis is made by the provider and the documented
signs and/or symptoms are inclusive to that diagnosis, do not report signs and symptoms i.e. patient has
flu, cough and fever (only code flu).
Describe the differences among screening, diagnostic and therapeutic procedures.
A screening procedure is considered routine based on a patient's risk factors such as age, and family
history (colonoscopy). A diagnostic procedure is done with the intent to rule out or determine a
diagnosis based on the images or findings obtained by a procedure - usually, the patient will exhibit
signs or symptoms that deem the procedure as being medically necessary (colonoscopy to determine
root cause of rectal bleeding). A therapeutic procedure is one that is aimed at treating an already
established disease or condition (removing a polyp or lesion).
What is the postoperative global period?
Defined by Medicare as "the necessary services normally furnished by a surgeon before, during and
after a procedure." Including biopsy results, follow-up incision care, and any post-op complications
arising from the initial procedure.
Describe a circumstance in which a separate evaluation and management (E/M) would be billed
during the postoperative global period of a procedure.
If an unrelated condition arrises during the postoperative global period that requires care, that service
can be separately reported. Example: findings from a diagnostic procedure show an illness that requires
PREP
Why is it important for all coding professionals to adhere to the same coding rules and conventions
when assigning ICD-10-CM and CPT codes?
Consistency in data. Coded data are reviewed not only for reimbursement purposes, but for researchers
to track public health and for the government to measure quality and safety practices. These data are
collected for present and future use. However, in order for the data to be reliable and accurate, the
same coding rules and conventions need to be followed by everyone. When coders allow
reimbursement to inappropriately influence code assignment, they could potentially be putting their
physician or entity at risk for audits, fines and negative publicity.
Discuss when a symptom should be reported.
Symptoms are reported when a definitive diagnosis is not made by the provider. Example: If the
documentation only states that the patient presents with a cough and fever, codes for the cough and
fever should be reported. When a definitive diagnosis is made by the provider and the documented
signs and/or symptoms are inclusive to that diagnosis, do not report signs and symptoms i.e. patient has
flu, cough and fever (only code flu).
Describe the differences among screening, diagnostic and therapeutic procedures.
A screening procedure is considered routine based on a patient's risk factors such as age, and family
history (colonoscopy). A diagnostic procedure is done with the intent to rule out or determine a
diagnosis based on the images or findings obtained by a procedure - usually, the patient will exhibit
signs or symptoms that deem the procedure as being medically necessary (colonoscopy to determine
root cause of rectal bleeding). A therapeutic procedure is one that is aimed at treating an already
established disease or condition (removing a polyp or lesion).
What is the postoperative global period?
Defined by Medicare as "the necessary services normally furnished by a surgeon before, during and
after a procedure." Including biopsy results, follow-up incision care, and any post-op complications
arising from the initial procedure.
Describe a circumstance in which a separate evaluation and management (E/M) would be billed
during the postoperative global period of a procedure.
If an unrelated condition arrises during the postoperative global period that requires care, that service
can be separately reported. Example: findings from a diagnostic procedure show an illness that requires
