CCS-P Medical Coding case studies
CCS-P Medical Coding · Put your knowledge to work in context.
The Certified Coding Specialist – Physician-based (CCS-P) is a health information credential administered by the American Health Information Management Association (AHIMA). It is designed for coders who work in physician practices, clinics, and other outpatient physician-service settings, where the medical record is typically shorter than a hospital inpatient chart and the emphasis falls on evaluation and management services, office-based procedures, and surgical coding rendered in a non-facility setting. The CCS-P Medical Coding case studies are 5 cases and about 3,388 words.
1Diabetic CKD, Neuropathy, and the 'With' Convention
A 68-year-old man with type 2 diabetes mellitus, diabetic peripheral neuropathy, and chronic kidney disease stage 3b is seen in the nephrology clinic for follow-up. The problem list reads: 'T2DM'; 'CKD 3b - stable, creatinine 2.1'; 'neuropathy, diabetic.' The assessment names the diabetes and the CKD but does not state a causal link between them, and no CKD stage appears in the body of the note.
670 words, about 3 min2Screening Colonoscopy That Becomes Therapeutic
A 62-year-old average-risk Medicare patient presents for a screening colonoscopy; the order sheet carries Z12.11. The endoscopist advances to the cecum with a good prep.
601 words, about 3 min3The Operative Note That Never States a Size
An office procedure note for a 45-year-old reads: 'Excision of lesion, left forearm. Lesion excised with ellipse and sent to pathology.
695 words, about 3 min4Blanket 'Incident-To' Billing for NP Visits
A Medicare patient established to a five-physician primary care practice is seen by a nurse practitioner for a new complaint of intermittent dizziness with one near-syncope episode. The NP takes the history, examines the patient, orders an ECG and labs, and starts a workup; the medical decision making supports 99214.
684 words, about 3 min5E/M Distribution Shift After a Template Rollout
A five-provider family practice deployed a new EHR visit template in January. By the second quarter, 99214 use rose from 34% to 61% of established-patient visits and 99213 fell correspondingly; 99212 essentially disappeared.
738 words, about 4 min