CCS Exam

The CCS credential is the most recognized and sought after medical coding certification in the facility coding community.

The exam is four hours long, is offered in almost every state year round, and provides multiple career options.

Learn More About the CCS Exam Below:

• Application and Membership
• Exam Details
• Examination Tools
• Examination Rules
• Exam Results
• Exam Anxiety

CCS Exam Details

• Multiple Choice
• Coding Cases

This part of the exam consists of sixty multiple choice questions and is assigned sixty minutes for completion.

Coding Cases: This portion of the CSS exam consists of thirteen medical records that must be read and accurately coded within three hours.

The thirteen medical records include both inpatient and outpatient charts. There are:

• 6 inpatient records
• 4 ambulatory surgery (outpatient)
• 1 emergency department (outpatient)
• 2 Cardiac Cath/Interventional Radiology/Pain Management records

Once part II of the exam has been given the examinee cannot return to part I.

The CCS exam tests the examinees in nine main areas:

• Health Information Documentation
• Diagnosis Coding
• Procedure Coding
• Regulatory Guidelines and Reporting Requirements for Acute Care (Inpatient) Services
• Regulatory Guidelines and Reporting Requirements for Outpatient Services
• Data Quality and Management
• Information and Communication Technologies
• Compliance
• Privacy, Confidentiality, Legal, and Ethical Issues

Health Information Documentation:

This portion of the exam makes up fifteen percent of the exam grade.

These questions determine whether an individual has the ability to:

~ Read a medical record
~ Recognize and understand: anatomy, pharmacology, and other medical terms
~Decide what is code able information and when more documentation is required
~Identify patient encounter type, post charges, and utilize other medical resources

Diagnosis Coding/Procedure coding: (National Level I and II codes)

Each of these question types make up twenty percent of the medical coding exam grade (40% combined).

Areas being evaluated through these questions include:

~Accurate medical record interpretation
~Ability to extract pertinent information
~Proper code assignment according to in or outpatient reporting requirements
~Solid understanding of coding conventions, guidelines, code sequencing, and proper code linkage

Regulatory Guidelines and Reporting Requirements for Acute Care (Inpatient) Services:

Questions and tasks pertaining to this area carry ten percent of the grade weight.

Items evaluated here include:

~Principal diagnosis and procedure selection
~Identification on: complications, co-morbid conditions, and any other diagnosis or procedures that would require coding according to the UHDDS definitions and Coding Clinic for the ICD-9-CM.
~Demonstrate an understanding of how code selections impacts DRG assignments ~Ability to verify DRG assignments based on IPPS definitions ~Proper assignment of appropriate discharge dispositions

Regulatory Guidelines and Reporting Requirements for Outpatient Services:

Questions pertaining to this category carry a grade weight of ten percent.

Examinees will be evaluated in this area by their:

~Ability to select the chief complaint, pertinent secondary conditions, any primary procedures, and pertinent secondary procedures according to UHDDS definitions, CPT Assistant, Coding Clinic for ICD-9-CM, and HCPCS.
~Knowledge of OPPS requirements regarding Modifiers, National level I and II codes, medical necessity, and E/M code assignments for facilities.

Data Quality and Management:

Exam questions pertaining to this area carry an overall weight of eight percent.

Items evaluated in this area will pertain to:

~Health provider education regarding payment methodologies, documentation regulations, and coding related guidelines.
~The ability to determine if a medical record is accurately documented
~The ability to utilize tools such as CCI edits, MCE, and OCE.

Information and Communication Technologies:

Questions regarding this portion of the exam are worth five percent of the exam grade.

This area of the exam determines if an individual has:

~Required computer skills such as: the ability to collect, store, and analyze data, and the ability to access reporting information.
~ Basic word processing, spread sheet, and e-mail skills.
~The ability to access and utilize specialized software to complete HIM processes.

Compliance:

CCS exam questions pertaining to compliance are worth six percent of the exam grade.

Areas evaluated through these questions include:

~Familiarization of the creation process and purpose of institutional coding polocies
~ The ability to evaluate a medical record for accuracy and completeness according to both organizational and external policies
~Ability to understand the process for recognizing and reporting compliance concerns

Privacy, Confidentiality, Legal, and Ethical Issues:

Questions regarding this topic carry six percent of the exam grade.

These questions are used to evaluate:

~Ability to execute ethical coding according to AHIMA's code of ethics
~Understanding regarding patient confidentiality laws and personal health disclosures
~Ability to recognize and report privacy issues
~Knowledge of data integrity and validity concerning software and hardware

CCS Examination Tools

The CCS exam is taken at a prometric testing center. Since each testing center is different it is up to the examinee to contact their individual center once they are registered and ask what supplies will be provided and which supplies they should bring.

Each examinee is allowed to bring an approved edition of the CPT and ICD-9-CM.

The CPT must be published by the AMA and may be either the standard, professional, or deluxe edition.

The ICD-9-CM must have Volumes I, II, and III. Approved ICD-9-CM publishers and book editions include:

• AMA Hospital ICD-9-CM Volumes 1,2 and 3
• CHANNEL ICD-9-CM; Generic Hospital Version: The Educational Annotation Annual Hospital Version; or The Education Annotation Hospital Version
• CONTEXO ICD-9-CM Volumes 1,2 and 3: Professional for Hospitals and Payers
• ELSEVIER ICD-9-CM Volumes 1,2 and 3: Standard or Professional Edition
• HCPRO ICD-9-CM Manual Volumes 1,2,and 3
• INGENIX ICD-9-CM Volumes 1,2 and 3: Expert for Hospitals; Professional for Hospitals; or Expert for Hospitals (updatable)
• MAG Mutuals ICD-9-CM Volumes 1,2 and 3: Professional
• MEDICAL MANAGMENT INSTITUTE ICD-9-CM Volumes 1,2 and 3; Professional for Hospitals and Payers
• PMICICD-9-CM Volumes 1,2 and 3: Binder Edition; Hospital Edition (indexed); Standard Edition; Expert for Hospital (updateable)
• SAUNDERSICD-9-CM Volumes 1,2 and 3: Standard Edition; Professional Edition

Examinees are also allowed / required to bring:

~ A medical dictionary
~ Personal hand written notations, comments, and tabs in their coding books

Notations must not include coding guidelines or rules taken from other coding references (ex.CPT assistant). Books containing excessive notations or containing information that is considered an "unfair advantage" will disqualify an examinee as well. Loose materials such as post it notes, photo copies, ect. are also exempt.

~ Two forms of current identification; one with a photo

Acceptable forms of identification include: driver's license, government ID card, current passport, credit or debit card, student ID card, or employee ID card.

CCS Exam Rules

Upon arrival individuals will need to provide two forms of identification. One form of identification must have the individual's photograph, and both forms of ID must be current.

Once signed in a picture is taken of each examinee. This picture is later printed on the examination results once the CCS exam has been completed.

Examinees are then directed to a secure storage area for their belongings.

Prohibited items in the testing area include:

• Food
• Drinks
• Bags
• Purses
• Calculators
• Cell phones
• Most electronic devices

Prior to starting the exam there is a twenty minute period in which tutorials and computer simulations are shown in order to familiarize examinees with the software.

Once part I of the exam begins examinees have one hour to complete the sixty multiple choice questions.

At the end of the first hour a mandatory ten minute break must be taken. Upon returning from the break individuals begin part II of the CCS exam.

Part II of the exam give examinees three hours to fully read and code the thirteen medical charts that are provided.

Once the examination time has expired exam scores will be given by the testing staff. If for some reason the testing results are not available they will be mailed.

Those with passing scores will be awarded the CCS credential and will be published on AHIMA website.

Individuals who do not pass on their first attempt must wait a minimum of 91 days before testing again. A new application and application fee is also required in order to sit for the CCS exam again.

CCS Exam Anxiety

• Dress in layers. Always expect all extremes by layering. Being comfortable physically calm your nerves.
• Leave early or drive to the test site a few days before the exam. By knowing exactly where you are going and how long it takes to get there you will have less s stress.
• Mint calms the stomach. Buy some mint gum, mentos, or candy to have in your mouth prior to testing or to take during your break.
• Call the testing center. Asking them questions and voicing your concerns may help you fully prepare and may ease some tension.
• Don't study the night before. Give your mind a rest, get a good night's sleep, and eat a good meal beforehand.