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Section 1
Assign diagnosis and procedure codes from provider documentation
Preview
Preview: 1. Coding Knowledge and Skills (39–41%)
Preview includes- 4 of 10 lesson topics
- 1 overview segment
- 3 core concepts
- 2 exam tips
Lesson Topics
- 2026 CCS exam structure and required code books
- ICD-10-CM diagnosis coding across inpatient, outpatient, and ED settings
- ICD-10-PCS inpatient procedure coding
- CPT and HCPCS Level II outpatient procedure/service coding
Overview
This is the broadest CCS coding objective: convert the health record into accurate ICD-10-CM, ICD-10-PCS, CPT, and HCPCS-coded data using the correct code set for the setting and the official conventions that govern it.
Core Concepts
- ICD-10-CM is used to report diagnoses in inpatient and outpatient settings; ICD-10-PCS is used for procedures performed during hospital inpatient stays; CPT/HCPCS are used for hospital outpatient and other applicable professional/service reporting.
- Never assign a code from the Alphabetic Index alone. Locate the term in the Index, then verify the code, required characters, inclusion terms, exclusions, and instructional notes in the Tabular List.
- Code to the highest level of specificity supported by the record. Do not manufacture laterality, acuity, episode-of-care, causal relationships, or clinical details that are not documented or supported by an official guideline.
Exam Tips
- Know which code set belongs to which setting before doing anything else.
- Use your code books actively: Index, Tabular, definitions, notes, and appendices are part of the testing strategy.
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Section 2
Resolve conflicting documentation
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Section 3
Ensure record completeness and accuracy
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Section 4
Identify the principal or first-listed diagnosis
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Section 5
Identify an ethical compliant query
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Section 6
Distinguish EHR types and functions
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Section 7
Apply coding conventions and regulatory guidance
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Section 8
Verify required documentation is present
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Section 9
Apply payer-specific guidance
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Section 10
Apply CPT and HCPCS modifiers
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Section 11
Sequence diagnoses and procedures
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Section 12
Validate the health record before final coding
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Section 13
Identify PSI and HAC reporting issues
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Section 14
Apply present-on-admission guidelines
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Section 15
Recognize a leading query
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Section 16
Use encoder and grouper software appropriately
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Section 17
Apply NCCI and medical-necessity edits
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Section 18
Protect health information under HIPAA
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Section 19
Apply DRG and APC reimbursement concepts
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Section 20
Abstract required health-record data
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Section 21
Apply ethical coding standards
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Section 22
Identify MCC and CC impact
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Section 23
Identify a documentation query opportunity
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Section 24
Evaluate computer-assisted coding output
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Section 25
Apply UHDDS data definitions
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Section 26
Apply HITECH-related safeguards
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