CCA (AHIMA) case studies
CCA · Put your knowledge to work in context.
The Certified Coding Associate (CCA) is a health information credential administered by the American Health Information Management Association (AHIMA), which lists it among its certifications alongside resources such as 'About The Exams,' 'Apply to Take an Exam,' and 'Recertify.' It is generally pursued by people entering the health information and coding workforce - students in HIM or coding certificate programs, new graduates, and staff moving from registration, billing, or clinical support roles into coding - as a way to demonstrate foundational coding competence before advancing to higher-level AHIMA coding credentials. Preparation usually combines a structured review of health record content and documentation, hands-on code assignment practice with the current ICD-10-CM/PCS and CPT/HCPCS code sets and official guidelines, health care data and statistics, compliance and reimbursement, and health information technology, reinforced by large volumes of practice questions with rationales. The CCA case studies are 5 cases and about 3,972 words.
1The Unsigned Op Note and the Post-Discharge Addendum
Riverside Community Hospital (210 beds) enforces a 30-day delinquency rule in its medical staff bylaws. On March 3, the HIM analyst reviews the chart of a patient discharged February 18 following a laparoscopic cholecystectomy.
664 words, about 3 min2"Rule Out" in the ED, "Probable" on the Floor
A 54-year-old woman presents to the emergency department on May 6 with right upper quadrant pain, nausea, and a temperature of 100.8°F. The ED note reads "rule out acute cholecystitis." The ultrasound is equivocal and no HIDA scan is performed.
705 words, about 4 min3Two Discharge Counts and One Annual Report
The HIM director of a 300-bed hospital prepares the annual statistical report. The EHR discharge/transfer/death (DTD) module reports 4,120 inpatient discharges for the year; patient accounting reports 4,205.
772 words, about 4 min4The Modifier 25 Request
A four-physician orthopedic practice bills Medicare and two commercial payers. In March, 12 claims for 99214 with modifier 25 billed alongside 20610 (arthrocentesis, major joint) are denied as bundled.
916 words, about 5 min5The Template That Wrote Its Own Review of Systems
During a post-go-live audit of 30 emergency department records at a 180-bed hospital, the HIM analyst finds that the chest-pain template auto-inserts "denies shortness of breath, denies diaphoresis, denies nausea" plus a ten-system review of systems, whether or not anything was asked. In 26 records the auto-text is unchanged; in 5 of those, the physician's free-text HPI contradicts it (one reads "diaphoretic on arrival").
915 words, about 5 min