CCS (AHIMA) case studies
CCS · Put your knowledge to work in context.
The Certified Coding Specialist (CCS) is an AHIMA credential for individuals skilled in classifying medical data from medical records. CCS holders demonstrate tested skills in data quality and accuracy as well as mastery of coding proficiency, and the coded data they produce is used by hospitals and providers to obtain reimbursement from insurers and government programs such as Medicare and Medicaid; researchers and public health officials also use it to monitor patterns and explore new interventions. The CCS case studies are 5 cases and about 3,597 words.
1Hypertension, Heart Failure, and CKD: The Combination-Code Decision
R, 68, is admitted 3/14 with worsening dyspnea and a 6 lb weight gain. The discharge summary (3/18) lists: 'Acute on chronic diastolic heart failure, EF 55%'; 'Hypertension'; 'Hypertension with CKD stage 4'; 'CKD stage 4, baseline creatinine 2.0-2.2, unchanged'; 'History of gout.' No other cardiac or renal diagnoses appear.
673 words, about 3 min2Documented but Unsupported: UTI, an Unsigned Note, and a Record About to Be Billed
Community hospital, inpatient. L, 81, is admitted from a skilled nursing facility with confusion and poor oral intake.
692 words, about 3 min3The Infected Decubitus: Writing a Query That Survives an Audit
N's progress note reads: 'Infected sacral decubitus - continue vancomycin.' The wound care nurse documents a 4 cm sacral wound with slough, foul odor, and 2 cm of surrounding erythema in a patient with paraplegia. A wound culture collected on the day of admission grows MRSA; blood cultures are negative; temperature was 38.6 C on admission only; lactate 1.4; no hypotension.
758 words, about 4 min4Same-Day E/M and Injection: Modifier 25, Time, and a Request to Pad the Diagnosis
Internal medicine group, Medicare patient. Encounter on 4/22: established patient with chronic right knee osteoarthritis.
708 words, about 4 min5After CAC Go-Live: Copy-Forward, an Outdated Grouper, and a Problem List That Codes Itself
Three months after a computer-assisted coding (CAC) go-live at a 300-bed hospital, the tool's suggestion acceptance rate is 94%. An internal audit of 30 inpatient records finds: 6 records in which an active diagnosis appears only in text copied forward from a prior admission; 3 records grouped with last year's DRG grouper because the encoder update was deferred; 2 records in which a problem-list entry of 'history of COPD' was suggested by CAC and accepted as active COPD.
766 words, about 4 min