Diagnosis Coding
24-26%of exam
ICD-10-CMFirst-Listed DxExcludes1/2LateralitySequela
Procedure Coding
28-32%of exam
CPT/HCPCSE/M MDMModifiersGlobal SurgeryNCCI EditsScenario Picker
Research
6-10%of exam
Compliance
18-22%of exam
Compliant QueriesSignaturesHIPAAIncident-ToSplit/SharedABN
Revenue Cycle
14-18%of exam
RBRVSHCCsDenialsMultiple SurgeryTimely Filing
Quick Facts
- Exam
- CCS-P
- Credential
- AHIMA physician-based coding
- Questions
- 121 (97 scored, 24 pretest)
- Time
- 4 hours total appointment time
- Pass
- Scaled 300 (100-400)
- Retake
- 90-day wait minimum
- Format
- Pearson VUE test center
- Blueprint
- Effective 05/01/2024
Excludes1 vs Excludes2
Excludes1
- Never code together
- True code conflict
- Exception: unrelated conditions
Excludes2
- Can code together
- Not part of code
- Both allowed if documented
Conflict vs coexistence
ICD-10-CM Conventions
- Excludes1
- Never code together
- Excludes2
- Can code together
- Combination code
- One code, two diagnoses
- Code first
- Etiology sequenced first
- Use additional code
- Add manifestation code
- 7th character S
- Sequela (late effect)
- Unspecified laterality
- Rarely used code
- With
- Links two conditions
Outpatient Diagnosis Rules
- First-listed dx
- Reason for visit
- Uncertain dx
- Code to certainty only
- Coexisting conditions
- Code if they affect care
- Chronic conditions
- Code when treated or relevant
- Resolved signs/symptoms
- Drop after confirmed dx
- Z codes
- Health status, not illness
- History Z code
- Past condition, affects care
- BMI/ulcer stage
- Non-provider can document
MDM 2-of-3 Rule
Meet 2 of 3: problems, data, risk
Problems: addressed todayData: orders/review/interpRisk: management decisionsHighest element alone doesn't control
Modifier 25 vs 59
Modifier 25
- Separately identifiable E/M
- Appended to E/M code
- Same day as procedure
Modifier 59
- Distinct non-E/M service
- Different session or site
- Never on E/M codes
E/M vs non-E/M
E/M Level Picker
- Office/outpatient visit, MDM known→Apply 2-of-3 MDM rule(Not ED)
- ED visit (99281-99285)→Level by MDM only(No time option)
- Hospital, obs, NF, or home visit→MDM or time (2023+)
- Know total same-day physician time→Select time-based level(Physician/QHP time only)
- Separate E/M on procedure day→Modifier 25(Significant, separate service)
E/M MDM Elements
- Problems
- Addressed this encounter
- Data
- Orders, review, interpretation
- Risk
- Management decision complications
- 2-of-3 rule
- Meet 2 of 3 elements
- Straightforward
- Lowest MDM level
- Low
- Second MDM level
- Moderate
- Third MDM level
- High
- Highest MDM level
Global Period Math
000 = day; 010 = +10; 090 = 1 + 90
000: endoscopy/minor, day only010: minor, +10 days090: major, day before +9092 total days in 090
Modifier 78 vs 79
Modifier 78
- Unplanned return to OR
- Related to original procedure
- No new global period
Modifier 79
- Unrelated to original procedure
- Paid at normal rate
- Starts new global period
Related vs unrelated return
Modifier Picker
- Distinct non-E/M same-day service→Modifier 59(Or X{EPSU} if specific)
- More specific X modifier fits→XE, XS, XP, or XU(Preferred over 59)
- Staged or related post-op procedure→Modifier 58(Resets global period)
- Unplanned return to OR/procedure room→Modifier 78(No new global starts)
- Unrelated procedure in global period→Modifier 79(Starts new global period)
- Second through fifth same-day procedure→Modifier 51(Paid at 50%)
E/M Time & ED Rule
- Time-based E/M
- Same-day physician time only
- 2021 overhaul
- Office visits: MDM or time
- 2023 extension
- Most other E/M families
- ED 99281-99285
- MDM only, no time
- Excluded time
- Staff time, other days
- Non-face-to-face time
- Counts if same day
Modifier 59 Order
Try X{EPSU} first; use 59 last
XE: separate encounterXS: separate structureXP: separate practitionerXU: unusual, non-overlapping
Key Modifiers
- 25
- Separate E/M same day
- 59
- Distinct non-E/M service
- XE
- Separate encounter same date
- XS
- Separate organ/structure
- XP
- Different practitioner
- XU
- Unusual non-overlapping service
- 58
- Staged procedure, resets global
- 78
- Unplanned return, no new global
- 79
- Unrelated procedure, new global
- 51
- Additional procedure, 50% pay
Global Periods & NCCI
- 000 global
- Day of procedure only
- 010 global
- Day of plus 10 days
- 090 global
- 92 days: day before + 90
- PTP indicator 0
- No modifier override
- PTP indicator 1
- Modifier may override
- MUE
- Max units per day
- Column 1/Column 2
- Payable code/denied code
- Multiple surgery
- 100% then 50% rule
NCD vs LCD
NCD
- National Medicare coverage rule
- Binds every MAC
- Set by CMS centrally
LCD
- Contractor-specific coverage rule
- One MAC jurisdiction only
- Must follow NCD
National vs local rule
Authoritative Sources
- Coding Clinic
- Official ICD-10-CM/PCS advice
- CPT Assistant
- Official AMA CPT advice
- NCD
- National Medicare coverage rule
- LCD
- Contractor-specific coverage rule
- Medicare NCCI
- Medicare bundling edits
- Medicaid NCCI
- State Medicaid bundling edits
- CAC
- NLP suggests, coder verifies
Compliant Query Formats
Open, multiple-choice-plus-other, or limited yes/no
Never highlight the answerNever cite reimbursement impactAlways let provider answer freelyMultiple-choice needs an "other"
Billing Model Picker
- Office, physician actively supervises NPP→Bill incident-to(100% of fee schedule)
- Hospital/SNF, physician+NPP same visit→Bill split/shared visit(Modifier FS required)
- 010/090-global service, virtual request→Require in-person supervision(42 CFR 410.26 exception)
- Behavioral health incident-to supervision→General supervision allowed
- Service likely denied, ABN signed→Modifier GA(Patient can be billed)
- Service likely denied, no ABN→Modifier GZ(Patient cannot be billed)
Compliant Query Formats
- Open-ended
- Free-text clinical answer
- Multiple-choice
- Must include "other"
- Limited yes/no
- Confirms, doesn't create new dx
- Non-leading
- No desired answer shown
- Reimbursement mention
- Non-compliant practice
- Clinical indicators
- Must support every query
Prospective vs Retrospective Audit
Prospective
- Reviews before submission
- Catches errors pre-billing
- Prevents denials upfront
Retrospective
- Reviews after submission
- Finds patterns for training
- Supports recovery or reporting
Before vs after billing
Query Format Picker
- Indicators support specific answer choices→Multiple-choice query with other(Must include "other")
- Need open clinical explanation→Open-ended query
- Confirming an already-documented condition→Limited yes/no query(Not a new diagnosis)
- Desired answer highlighted or implied→Non-compliant: avoid leading(Redo without hints)
Signatures, HIPAA & ABN
- Handwritten/electronic
- Both acceptable
- Stamped signature
- Not acceptable
- Signature log
- Resolves illegible signature
- Attestation
- Author signs and dates
- Minimum necessary
- Doesn't apply to treatment
- ABN
- Warns of likely denial
- GA modifier
- ABN on file, billable
- GZ modifier
- No ABN, not billable
Denial Types Checklist
Technical, eligibility, auth, necessity, bundling
Technical: fixable, resubmitEligibility: registration problemNecessity: diagnosis doesn't supportBundling: NCCI edit fired
CARC vs RARC
CARC
- States payment reason
- Required on every adjustment
- Drives appeal strategy
RARC
- Adds remark detail
- Explains CARC further
- May be informational only
Reason vs remark code
Payment & Risk Adjustment
- Work RVU
- Physician time, intensity
- PE RVU
- Overhead, staff, supplies
- MP RVU
- Liability insurance
- GPCI
- Geographic cost adjustment
- Conversion factor
- Dollars per RVU
- HCC
- Risk-adjusted diagnosis group
- Risk score
- Prior-year dx set next year
Claims & Denials
- CARC
- Why payment differed
- RARC
- Extra remark detail
- Technical denial
- Clerical, resubmittable
- Medical necessity denial
- Dx doesn't support service
- Bundling denial
- NCCI edit triggered
- Timely filing
- 12 months from service
- Dx-to-procedure link
- Required on every line
Common Traps
Uncertain Diagnosis: Outpatient vs Inpatient
Outpatient: code to certainty only ≠ Inpatient: code as if confirmed
Excludes1 vs Excludes2 Confusion
Excludes1 blocks both codes ≠ Excludes2 allows both codes
ED E/M Leveling Trap
ED uses MDM only ≠ Time never levels ED visits
Modifier 59 vs 25 Mixup
59 is never on E/M ≠ 25 is only on E/M
Incident-To vs Split/Shared Site
Incident-to: non-institutional settings ≠ Split/shared: hospital or SNF only
PTP Modifier Indicator Mixup
Indicator 0 blocks any override ≠ Indicator 1 allows modifier override
ABN Modifier GA vs GZ
GA means ABN on file ≠ GZ means no ABN filed
Last Minute
- 1.121 Qs: 97 scored, 24 pretest
- 2.4-hour Pearson VUE appointment
- 3.Pass = scaled 300 of 400
- 4.Diagnosis 24-26%; Procedure 28-32%
- 5.Research 6-10%; Compliance 18-22%
- 6.Revenue Cycle 14-18% of exam
- 7.Scenarios: E/M, Surgery, Medicine equal
- 8.ED visits: MDM only, no time
- 9.MDM needs 2 of 3 elements
- 10.90-day wait before retake application
- 11.Bring exact current-year codebooks only
- 12.Incident-to needs direct physician supervision
- 13.Split/shared bills by substantive portion
Third-party resources · We may earn a commission from purchases.
CCS-P Exam Study Guide - 2023 Edition: 115 Certified Coding Specialist Practice Exam Questions, Answers, and Rationale, Over 180 Coding Tips! Medical Terminology, Common Anatomy, and Scoring Sheets
By Coding Pro, Medical
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