AHIMA CCS-P Study Review
1. 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
2. CPT Assistant: provides official guidance in CPT coding
published by the AMA
3. A barrier to wide spread use of automated code assignments is: poor quality of
documentation
4. 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 treat- ment; consult with the
physician as to whether the Dx should be added or if an abnormal finding should be listed.
5. 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
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AHIMA & AHA: give advice & assistance on coding guidelines in conjunction with health
information management practitioners, physicians, & other users of ICD-9
6. 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
7. 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.
8. When does CMS send the payment directly to the patient: when a NON PAR provider does
not accept assignment
9. hard coding: refers to CPT/HCPCS codes that appear in the hospitals charge- master and
will be included automatically on the patient's bill.
10. CAC- computer assisted coding: AHIMA defines as the use of computer soft- ware that
automatically generates a set of medical codes for review , validation, and use based upon the
documentation provided by the various providers of healthcare.
11. modifier: A1-principle physical of record: required for patients covered by Medicare
when reporting Initial Hospital Service codes
12. POMR- PROBLEM ORIENTED MEDICAL RECORD: Organized by problem number
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Database: history and physical
Problem List: titles, numbers, dates of problems..."Table of Contents" of the record
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