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Number of Questions on exam:
=> 97 multiple-choice questions (79 scored/18 pretest)
=> 8 medical scenarios (6 scored/2 pretest)
Exam Time: 4 hours – no breaks
Domain 1 – Health Information Documentation (8-10%)
1. Interpret health record documentation using knowledge of anatomy, physiology, clinical indicators and disease processes, pharmacology and medical terminology to identify codeable diagnoses and/or procedures
2. Determine when additional clinical documentation is needed to assign the diagnosis and/or procedure code(s)
3. Consult with physicians and other healthcare providersto obtain further clinical documentation to assist with code assignment
4. Compose a compliant physician query
5. Consult reference materialsto facilitate code assignment
6. Identify patient encounter type
7. Identify and post chargesfor healthcare services based on documentation
Domain 2 – Diagnosis & Procedure Coding (64-68%)
1. Select the diagnosesthat require coding according to current coding and reporting requirementsfor acute care (inpatient) services
2. Select the diagnosesthat require coding according to current coding and reporting requirementsfor outpatient services
3. Interpret conventions, formats, instructional notations, tables, and definitions of the classification system to select diagnoses, conditions, problems, or other reasonsfor the encounter that require coding
4. Sequence diagnoses and other reasons for encounter according to notations and conventions of the classification system and standard data set definitions(such as Uniform Hospital Discharge Data Set [UHDDS])
5. Apply the official ICD-10-CM coding guidelines
1. Select the proceduresthat require coding according to current coding and reporting requirementsfor acute care (inpatient) services
2. Select the proceduresthat require coding according to current coding and reporting requirementsfor outpatient services
3. Interpret conventions, formats, instructional notations, and definitions of the classification system and/ornomenclature to select procedures/servicesthat require coding
4. Sequence procedures according to notations and conventions of the classification system/nomenclature and standard data set definitions(such as UHDDS)
5. Apply the official ICD-10-PCS procedure coding guidelines
6. Apply the official CPT/HCPCS Level II coding guidelines
Domain 3 – Regulatory Guidelines and Reporting Requirements for Acute Care (Inpatient) Service (6-8%)
1. Select the principal diagnosis, principal procedure, complications, comorbid conditions, other diagnoses and proceduresthat require coding according to UHDDS definitions and Coding Clinic
2. Assign the present on admission (POA) indicators
3. Evaluate the impact of code selection on Diagnosis Related Group (DRG) assignment
4. Verify DRG assignment based on Inpatient Prospective Payment System (IPPS) definitions
5. Assign and/or validate the discharge disposition
DOMAIN 4. Regulatory Guidelines and Reporting Requirements for Outpatient Services (6-8%)
1. Select the reason for encounter, pertinentsecondary conditions, primary procedure, and other proceduresthat require coding according to UHDDS definitions, CPT Assistant, Coding Clinic, and HCPCS
2. Apply Outpatient Prospective Payment System (OPPS) reporting requirements:
b. CPT/ HCPCS Level II
c. Medical necessity
d. Evaluation and Management code assignment (facility reporting)
3. Apply clinical laboratory service requirements
DOMAIN 5. Data Quality and Management (2-4%)
1. Assess the quality of coded data
2. Communicate with healthcare providersregarding reimbursementmethodologies, documentation rules, and regulationsrelated to coding
3. Analyze health record documentation for quality and completeness of coding
4. Review the accuracy of abstracted data elementsfor database integrity and claims processing
5. Review and resolve coding edits such as Correct Coding Initiative (CCI), Medicare Code
Editor (MCE) and Outpatient Code Editor (OCE)
DOMAIN 6. Information and Communication Technologies (1-3%)
1. Use computer to ensure data collection,storage, analysis, and reporting of information.
2. Use common software applications(for example, word processing,spreadsheets, and email) in the execution of work processes
3. Use specialized software in the completion of HIM processes
DOMAIN 7. Privacy, Confidentiality, Legal, and Ethical Issues (2-4%)
1. Apply policies and proceduresfor access and disclosure of personal health information
2. Apply AHIMA Code of Ethics/Standards of Ethical Coding
3. Recognize and report privacy and/or security concerns
4. Protect data integrity and validity using software or hardware technology
DOMAIN 8. Compliance (2-4%)
1. Evaluate the accuracy and completeness of the patient record as defined by organizational policy and external regulations and standards
2. Monitor compliance with organization-wide health record documentation and coding guidelines
3. Recognize and report compliance concerns
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ORLANDO, Fla. â€” There at the moment are nearly 200 pharmacies in valuable Florida where seniors can get COVID-19 vaccines.
Retail outlets like Winn-Dixie, Walmart, and Publix printed the locations the place theyâ€™ll offer doses this week through the federal retail pharmacy COVID-19 vaccination application.
interior drugs professional Dr. Aftab Khan says many seniors still have questions on getting the vaccine.
one of the vital ordinary: should still an individual whoâ€™s already had COVID-19 nonetheless get the shot?
The short reply is sure. health officers recommend even though a person has had the virus, they should still still get the vaccine.
â€śif they had been in the past contaminated, they should be getting the vaccine within 90 days,â€ť Dr. Khan suggests.
Thatâ€™s as a result of proof means that an infection is unusual in the ninety days after initial an infection, in response to the facilities for sickness handle and Prevention. besides the fact that children, to be clear,Â the 90 day wait isnâ€™t a requirement.
yet another standard query: should still COVID-19 patients who received antibody remedies get vaccinated?
if that's the case, Dr. Khan says, you may also are looking to wait.
â€śThe total explanation for getting monoclonal antibodies, or plasma convulsive therapy, is to preserve you out of the hospitals,â€ť Dr. Khan says.
The CDC recommends delaying vaccination for as a minimum 90 days because itâ€™s doubtful how the antibodies from those two treatments may engage with the antibodies from the vaccine.
officers add, people who consider in poor health may still additionally delay a scheduled vaccination in favor of a COVID-19 verify.
â€śsimply as a usual measure, they donâ€™t provide vaccines to americans who suppose sick on the day they demonstrate up.â€ť
eventually, Channel 9 viewers requested what may occur if the CDCâ€™s tips is not noted and an individual obtained the vaccine within ninety days of getting an antibody medication.
The CDC says doing so might have an effect on the grownupâ€™s immune response, maybe inserting them at better risk of reinfection.
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