AHIMA CCS-P Cheat Sheet

Diagnosis Coding

24-26% of exam
ICD-10-CM First-Listed Dx Excludes1/2 Laterality Sequela

Procedure Coding

28-32% of exam
CPT/HCPCS E/M MDM Modifiers Global Surgery NCCI Edits Scenario Picker

Research

6-10% of exam
Coding Clinic NCD vs LCD CAC/NLP Payer Rules

Compliance

18-22% of exam
Compliant Queries Signatures HIPAA Incident-To Split/Shared ABN

Revenue Cycle

14-18% of exam
RBRVS HCCs Denials Multiple Surgery Timely 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 DI

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 DI

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 DI

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 PR

Meet 2 of 3: problems, data, risk
Problems: addressed today Data: orders/review/interp Risk: management decisions Highest element alone doesn't control

Modifier 25 vs 59 PR

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 PR

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 PR

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 PR

000 = day; 010 = +10; 090 = 1 + 90
000: endoscopy/minor, day only 010: minor, +10 days 090: major, day before +90 92 total days in 090

Modifier 78 vs 79 PR

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 PR

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 PR

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 PR

Try X{EPSU} first; use 59 last
XE: separate encounter XS: separate structure XP: separate practitioner XU: unusual, non-overlapping

Key Modifiers PR

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 PR

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 RE

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 RE

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 CO

Open, multiple-choice-plus-other, or limited yes/no
Never highlight the answer Never cite reimbursement impact Always let provider answer freely Multiple-choice needs an "other"

Incident-To vs Split/Shared CO

Incident-To

Non-institutional setting only
Physician directly supervises
Billed at 100% rate

Split/Shared

Facility settings only
Substantive portion sets biller
Flagged with modifier FS
Office vs facility visit

Billing Model Picker CO

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 CO

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 CO

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 CO

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 )

Incident-To & Split/Shared CO

Incident-to setting Not hospital or SNF
Direct supervision Physician immediately available
Virtual supervision Allowed since 2026
010/090-global exception In-person still required
Split/shared setting Facility settings only
Substantive portion Over half time, or MDM
Modifier FS Flags split/shared visit

Signatures, HIPAA & ABN CO

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 RE

Technical, eligibility, auth, necessity, bundling
Technical: fixable, resubmit Eligibility: registration problem Necessity: diagnosis doesn't support Bundling: NCCI edit fired

CARC vs RARC RE

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 RE

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 RE

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

AHIMA CCS-P Certified Coding Specialist Physician-based

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