ACA CCS cheat sheet

ICD-10-CM classifies diagnoses; ICD-10-PCS codes inpatient procedures; CPT and HCPCS Level II code outpatient services, supplies, and drugs.

The ICD-10-CM Official Guidelines for Coding and Reporting are organized by chapter and take precedence over individual code titles when selecting codes.

AHA Coding Clinic is the official source for ICD-10-CM/PCS coding advice; CPT Assistant is the AMA's official source for CPT guidance.

The Alphabetic Index is consulted first and the Tabular List verified second; a code is invalid if its Tabular List entry requires additional characters.

AHIMA and AAPC both publish codes of ethics; violations can result in membership sanctions, certification revocation, or both.

Query the provider when documentation is ambiguous, incomplete, or contradictory; the physician, not the coder, is the author of the diagnosis.

CCI edits define code pairs that cannot be reported together unless a modifier or documentation supports separate services.

Coding credentials (CPC, CCS, RHIT, RHIA) require continuing education units to maintain certification, typically 20-40 CEUs per cycle.

Prefix + root + suffix construction: 'gastr/o' (stomach) + '-ectomy' (surgical removal) = gastrectomy.

Suffixes: -itis = inflammation, -ectomy = surgical removal, -otomy = incision, -ostomy = creation of an opening, -plasty = repair, -megaly = enlargement.

Prefixes: tachy- = fast, brady- = slow, hyper- = above normal, hypo- = below normal, dys- = difficult or abnormal, a-/an- = without.

Anatomical planes: sagittal divides left/right, coronal divides anterior/posterior, transverse divides superior/inferior.

Directional terms: proximal = nearer the point of attachment, distal = farther; medial = toward midline, lateral = away from midline.

The diaphragm separates the thoracic cavity from the abdominal cavity; the abdominal quadrants are RUQ, LUQ, RLQ, LLQ.

Common pathophysiologic terms: neoplasm = new growth (tumor), benign = noncancerous, malignant = cancerous, metastasis = spread of malignancy.

Medical word roots commonly reference organs: hepat/o = liver, nephr/o = kidney, cardi/o = heart, pulmon/o = lung, oste/o = bone.

ICD-10-CM codes are 3-7 characters: first character is alphabetic, second is numeric, and characters 3-7 may be letters or digits.

Placeholder 'X' is used in the 6th character position when a 7th character is required but the 6th character is not otherwise used.

7th characters indicate encounter type (A = initial, D = subsequent, S = sequela) and apply only to codes whose Tabular List entry requires them.

External cause codes (V, W, X, Y) describe how an injury occurred and are never sequenced as the principal diagnosis.

Signs and symptoms that are integral to a confirmed diagnosis are not coded separately; symptoms are coded when no definitive diagnosis is documented.

Laterality (right, left, bilateral, unspecified) is required in many musculoskeletal and eye codes and must be documented to select a specific code.

Combination codes represent two diagnoses or a diagnosis with an associated manifestation, complication, or secondary condition in one code.

'Code first' notes indicate etiology/manifestation sequencing; 'use additional code' notes indicate mandatory secondary codes.

ICD-10-PCS codes are always exactly 7 characters, alphanumeric, with no decimal point.

The 7 characters are: Section, Body System, Root Operation, Body Part, Approach, Device, and Qualifier.

The root operation is the core of the code and describes the objective of the procedure (e.g., Excision, Resection, Reposition, Insertion).

Section values include 0 Medical and Surgical, B Imaging, 2 Placement, 3 Administration, 5 Extracorporeal Assistance, 9 Chiropractic.

Approach values include 0 Open, 3 Percutaneous, 4 Percutaneous Endoscopic, 7 Via Natural or Artificial Opening, F Via Natural or Artificial Opening Endoscopic.

The device character identifies whether a device was left in place (e.g., Z No Device, 0 Drainage Device) and must be documented.

Excision cuts out a portion of a body part; Resection cuts out the entire body part; both are distinguished by the extent documented.

Diagnostic procedures are coded with root operation Inspection or a diagnostic qualifier; PCS codes are assigned from operative reports, not from ICD-10-CM diagnoses.

CPT codes are 5 digits; Category I codes are numeric, Category II codes end in 'F', and Category III codes end in 'T'.

CPT modifiers: -25 = significant, separately identifiable E/M service on the same day; -59 = distinct procedural service; -51 = multiple procedures.

HCPCS Level II codes begin with a letter followed by 4 digits; J codes are drugs, A codes supplies, E codes DME, and V codes vision.

E/M level selection under 2021+ office/outpatient guidelines is based on medical decision making (MDM) or total time on the date of the encounter.

MDM has three elements: number and complexity of problems, amount/complexity of data reviewed, and risk of complications/morbidity/mortality.

Surgical package includes the procedure, local anesthesia, and typical postoperative care; a separate E/M within the global period requires modifier -24, -25, or -57.

Global surgical periods are 0 days (minor/endoscopic), 10 days (minor), or 90 days (major) postoperatively.

Add-on codes are never reported alone and are exempt from modifier -51; they are listed in Appendix D of CPT.

Revenue cycle phases: preregistration, registration, charge capture, coding, claim submission, denials management, and collections.

Clean claim rate and days in accounts receivable (A/R) are key performance indicators; A/R days = (total A/R / total charges) x days in period.

Inpatient MS-DRG payment is derived from the principal diagnosis, secondary diagnoses (CC/MCC), procedures, and discharge disposition.

APC (Ambulatory Payment Classification) groups outpatient services for Medicare OPPS payment; status indicators determine how a code is paid.

The Medicare Physician Fee Schedule pays by relative value units (RVU): work, practice expense, and malpractice, multiplied by the conversion factor.

Coordination of benefits determines primary versus secondary payer; Medicare Secondary Payer rules apply when another payer is primary.

Denial management involves root-cause analysis by CARC/RARC codes and timely resubmission or appeal within payer deadlines.

Charge capture integrity depends on accurate chargemaster maintenance and matching documented services to billed codes.

False Claims Act liability includes treble damages plus civil penalties for knowingly submitting false claims; qui tam relators may share in recoveries.

The Anti-Kickback Statute prohibits remuneration to induce referrals for items or services reimbursable by federal health care programs.

The Stark Law (Physician Self-Referral) prohibits physician referrals of designated health services to entities with which the physician has a financial relationship, absent an exception.

HIPAA Privacy Rule governs use and disclosure of PHI; the Security Rule covers electronic PHI; the minimum necessary standard limits disclosures.

The OIG Work Plan and the 7 elements of a compliance program (policies, compliance officer, training, communication, monitoring, discipline, response) frame coding compliance.

RAC, MAC, and UPIC audits review coding and documentation; internal audits should sample claims and trend error rates.

Upcoding (billing a higher level than documented) and unbundling (billing components separately) are common compliance risk areas.

AHIMA/AAPC ethical standards prohibit coding from undocumented diagnoses and require reporting inaccurate or fraudulent practices.

The medical record must be complete, legible, authenticated, and timely; late entries and addenda should be dated and signed.

Data quality dimensions include accuracy, completeness, timeliness, consistency, and validity; coding audits measure these dimensions.

The MPI (Master Patient Index) must uniquely identify each patient; duplicate or overlapped records are a leading HIM data integrity issue.

Release of information requires valid patient authorization unless an exception (treatment, payment, operations, or law) applies.

Retention schedules vary by state and payer; Medicare requires records be retained for at least 10 years.

Query practice: concurrent, retrospective, and verbal queries must be documented; leading queries are discouraged.

Data analytics such as case mix index (CMI) and severity distribution measure documentation and coding performance.

The legal health record is the official business record of the organization and may differ from the complete medical record.