By Kelli Horn, RHIT, CCS
Hundreds of coders and students desire to take the next step in their career by obtaining the Certified Coding Specialist (CCS) credential. This examination represents high-level achievement and proficiency in inpatient and outpatient coding and associated concepts. Benefits of certification include a potential growth opportunity in one’s coder career path, a possible salary increase, heightened employer confidence in skills and knowledge, and future unforeseen opportunities.
But the benefits of passing the exam don’t come easily. The test covers 97 multiple choice questions and eight medical scenarios adding up to a four-hour rigorous examination. Preparing for the examination while striving to balance work and family requires much energy. And it is challenging enough in its present ICD-9-CM form.
With the transition to an ICD-10-CM/PCS examination in the future, a whole new level of stress will be added to the equation. This move has led some potential test-takers to delay sitting for the exam. However, with the exam still reflecting ICD-9 content until ICD-10 has officially been implemented, coders have bought more unexpected time to take the exam.
Coding experts say that now is not the time for up-and-coming coders to hold back on becoming credentialed. ICD-10 has created a high demand for credentialed coders, and the workforce needs individuals with the CCS credential more than ever. While test-takers cannot control the ICD-9 or ICD-10 factor of the examination, they can concentrate on overcoming 10 specific challenges of taking the exam. Follow these guidelines, and one can breathe a little easier before hitting the exam room.
Some Lack Outpatient Coding Experience
Many inpatient coders feel very competent coding inpatient accounts and answering questions related to inpatient-related concepts. However, since these coders primarily code only inpatient accounts, many lack the coding knowledge and experience related to outpatient encounters.
To help combat this and get their coders the experience they need to sit for the CCS exam, some healthcare providers have offered to cross-train inpatient and outpatient coders. Ardent Health Services, a healthcare organization based in Nashville, TN, that owns and operates 12 acute care hospitals in Albuquerque, NM (Lovelace Health System), Tulsa, OK (Hillcrest HealthCare System), and Amarillo, TX (BSA Health System), has shown their strong commitment to their coders by currently offering on-the-job cross-training for outpatient coders who feel they lack inpatient coding skills. As a result, these coders have expanded their coding knowledge and skills, improved their versatility in being able to code more visit types, and have effectively prepared to pass a national coding exam. Ardent also provides cross-training opportunities for their inpatient coders to obtain outpatient coding knowledge and skills.
“It is valuable to have coders with both inpatient and outpatient coding experience to help with coverage,” says Terri Walker, RHIT, CCS, the MS-DRG manager of shared coding services at Ardent Health Services. Through the program, coders have the opportunity to complete outpatient coding education modules, pass a test, and then be promoted to Inpatient Coder II, which also modifies their job description and increases their salary. This would easily present an opportunity for the coders to gain the hands-on practice they need to pass the CCS examination.
Therefore, inpatient coders must use creativity to discover ways to obtain this experience. If hands-on experience is not possible at a coder’s facility, they could use printed tools to practice with outpatient coding, such as the Clinical Coding Workout with Answers book published by the AHIMA Press.
Not only do inpatient coders need to develop their outpatient coding skills, they need to become more familiar with outpatient-related concepts, including Outpatient Prospective Payment System (OPPS), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), Evaluation and Management (E/M), Correct Coding Initiative (CCI), Medicare Code Editor (MCE), Outpatient Code Editor (OCE), medical necessity, modifiers, and clinical laboratory service requirements.
There are some outpatient coders who have experience coding only ancillary visits, and lack the skills to code a variety of outpatient encounters including endoscopy and surgical procedures. These coders will also need to practice coding the full spectrum of outpatient visits either by purchasing a resource or obtaining on-the-job training experience.
State HIM Associations Offer Training
Several state health information management associations have taken the lead in hosting CCS exam review courses for their members. Three of the state associations doing this include the Oklahoma Health Information Management Association (OkHIMA), with courses in Tulsa and Oklahoma City; the Arkansas Health Information Management Association (ArHIMA), with courses in Ft. Smith and Little Rock; and the New York Health Information Management Association (NYHIMA), offering courses in New York City and Syracuse.
Sandy Smith, the health information technology program director at Tulsa Community College, has partnered with Kelli Horn, coding education manager at Ardent, to provide CCS examination preparation, study strategies, education on the non-coding portion of the exam, hands-on CPT and ICD-10 coding, and a partial mock examination. In addition, Smith and Horn provide ongoing follow-up support and host a Facebook group called “Pursuing the CCS, RHIT, and CCA Exam,” where members can post questions as they embark on their certification journey.
The benefit for an organization that has its coders participate in a review course is that it exposes the coders to inpatient and outpatient coding concepts and coding exercises, simulates the mock examination experience, creates a networking atmosphere with others who are also preparing to take their exam, and provides further education regarding the non-coding concepts on the examination.
Vanessa McCool, RHIA, the OkHIMA specialty workshop coordinator, has been instrumental in providing these workshops for OkHIMA. “I think it’s important for OkHIMA to continue to offer concurrent education for its healthcare members in an effort to keep up with the rapid changes of the industry, not only for coders, but for all healthcare related employees in Oklahoma. The OkHIMA board strives to offer the best and most affordable education for members and non-members,” McCool says. “We value their healthcare and want to give our members and non-members learning opportunities that they can use to aid their careers.”
Some Lack Inpatient Coding Experience
Outpatient coders may feel comfortable coding ancillary and outpatient surgery accounts. However, many outpatient coders are lacking inpatient coding experience. Workplaces that provide on-the-job cross-training are the best option for coders preparing to take their exam. However, if this option is not available, coders may need to take the initiative and purchase resources that contain sample inpatient coding exercises and work beginning, intermediate, and advanced exercises, along with case studies, to develop inpatient coding skills.
These coders will also need to learn more about concepts associated with inpatient coding, including the Inpatient Prospective Payment System (IPPS) overview and definitions, Diagnosis Related Groups (DRGs), major complications or comorbidities (MCC), complication or comorbidity (CC), clinical documentation improvement (CDI), present on admission (POA), compliant physician queries, and discharge disposition. Furthermore, they will need to be prepared to code eight medical scenarios, which will include some inpatient cases.
Many Get Overwhelmed by the Coding Guidelines
Many coders feel overwhelmed by the Official Coding Guidelines developed by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). While many coders reference them, as needed, when they are coding their visits each day, some coders struggle at comprehending the material as a whole.
Things get especially tough for some when they are asked to recall and apply the material quickly on the CCS test, and many run out of time or barely have sufficient time to complete the exam. When the guidelines reflect ICD-10 instead of ICD-9, this will be one major area of concern for coders preparing to take the CCS. But this should not be a deterring factor in taking the exam, coding experts say. Coders are expected to become familiar with these guidelines in their daily workplace coding duties, which should serve as extra motivation to become familiar with ICD-10 at a higher level. Coders should read through the guidelines at least once, but preferably twice, before taking the exam.
Handling the Non-Coding Parts of the Exam
Between October 2013 and January 2014, an informal CCS examination preparation survey was conducted with CCS Exam Review Course participants from Oklahoma, Arkansas, New York, and students from Tulsa Community College. Several of the respondents surveyed at the New York Health Information Management Association (NYHIMA) review course were concerned about being able to successfully pass the non-coding portion of the exams. Many had been coding for several years, however, they had not been exposed to many of the domains included in the examination.
Data Quality and Management (three percent of the test), Information and Communication Technologies (two percent), Privacy/Confidentiality/Legal/Ethical Issues (three percent), and Compliance (three percent) are the indirect domains contained in the CCS examination. Topics include reimbursement methodologies, documentation rules and regulations, abstracted data elements for database integrity and claims processing, using technology to ensure data collection, analysis, storage, reporting of information, and use in HIM work processes. Privacy and security concerns, protection of data integrity, access and disclosure of personal health information, accuracy and completeness of the patient record, monitoring organization-wide compliance, and ethical coding standards are additional topics. These sections comprise 11 percent of the overall score on the examination.
Recommendations for overcoming this challenge include:
- Research selected health information topics, such as OPPS, clinical documentation, HIPAA, and general information technology issues within the AHIMA HIM Body of Knowledge, available at www.ahima.org.
- Initiate interactive conversations on AHIMA’s Engage Communities of Practice, available at engage.ahima.org/home, on topics such as Coding, Classification and Reimbursement; Confidentiality, Privacy, and Security; and Health Information Technologies and Processes.
Beating the Dreaded Clinical Scenarios
The clinical scenario portion of the CCS exam will probably present the biggest challenge for coders once the exam moves to include ICD-10, which won’t occur until after the new code set is implemented in the US. Coders must code eight medical record cases, which includes inpatient and outpatient encounters. Even before the code set changes to ICD-10, many coders feel nervous about this section. Since most coders have not had much exposure to hands-on ICD-10 coding, this is the area that could potentially become the biggest obstacle once ICD-10 is implemented. For clarification, while there can be questions regarding ICD-10 on the multiple choice section of the exam, there are no coding exercises that would involve ICD-10 until that code set has officially been implemented.
There are several steps coders can take to face their fear of this exam portion. Attending an ICD-10 workshop to become more familiar with ICD-10-CM and ICD-10-PCS concepts will make a significant difference. Furthermore, coders can purchase resources from AHIMA and other publishers to gain practice coding exercises using ICD-10. The Journal of AHIMA website, journal.ahima.org, also offers free weekly ICD-10-CM/PCS coding quizzes each Monday that can help coders become familiar with the new code set.
Anna Reynolds, CPC, CCS, a clinical coding specialist at Integris Health, based in Oklahoma, passed her CCS examination on her second attempt. When asked what she worked on between exams, she said “I took a CPT class, got a study buddy, and concentrated more on cases.” Practicing case studies cannot be overemphasized. Practice, then practice, then practice some more.
Not Using the Code Books Effectively
Several participants of the CCS Exam Review Course hosted by NYHIMA, the Oklahoma Health Information Management Association (OkHIMA), and the Arkansas Health Information Management Association (ArHIMA) have communicated their discomfort level of being able to assign codes effectively and efficiently using their code books. As a result, they have an opportunity to “get to know their code books” as they invest much time and effort in becoming familiar with it in preparation for the CCS exam. Future test-takers will benefit greatly from scanning over the Index to Diseases and the Tabular List, as well as other sections in the ICD-9 and ICD-10 code books, including V Codes, E codes, Appendices, Table of Drugs and Chemicals, Hypertension Table, Official Coding Guidelines, the Procedures section, and other sections. Becoming familiar with the index, guidelines, and chapters of the CPT coding book is also a must.
Effectively Managing Test Time Very Difficult
At a recent NYHIMA CCS Exam Review Course in New York City, 12 participants were asked what their greatest concerns were in taking the examination. The number one concern reported was running out of time. Following time, participants reported concerns with the low pass rate, not having ample on-the-job cross-training opportunities to gain knowledge and skills in coding outpatient surgeries, not having sufficient time in the workplace to keep current with Coding Clinics and CPT Assistants, and, finally, test anxiety. The overlying fear factor for all participants was having to take the examination with the ICD-10 code set sections included, as most indicated they were attending the review course in order to take the examination before the CCS examination will reflect ICD-10 codes.
The time factor is a valid concern for many reasons. Completing the test in four hours reflects that test-takers have mastered the material at a high cognitive level and can apply that information at a recall, application, or analysis level. Some test questions will require participants to identify facts, basic concepts, theories, processes, and principles. Other questions will require test-takers to apply principles and concepts to situations, recognize data relationships, and solve specific problems integrating various concepts into the solution. Therefore, it is imperative that test-takers have thoroughly studied the concepts listed on the CCS Examination Content Outline to increase their chances of answering questions accurately and quickly. Test-takers should simulate the timed test experience before the exam.
Attending Formal Coding Education
Students who have completed their formal coding education at a local community college, university, or through online distance learning have a great opportunity to pass the CCS examination. However, they may want to start with the CCA examination to build up to the mastery level of knowledge and skill required to pass the CCS exam.
“I encourage students without coding experience to start out with the CCA exam,” says Ellen Shakespeare Karl, MBA, RHIA, CHDA, FAHIMA, academic director of the health information management program at the City University of New York. “This will get their feet wet and give them a sense of accomplishment before even attempting the CCS exam.” She encourages her students to take the CCA exam during their tenure as a student soon after completing the program’s coding classes. Karl previously worked at a community college in New Jersey and had many students pass their CCA exam in this manner as well.
However, a few students are able to immediately take and pass the CCS exam. Those students who received above average grades in their ICD-9 and CPT coding classes, and other classes, including reimbursement, statistics, legal, and management, are typically able to combine their classroom learning with an excellent study strategy and successfully pass the examination on the first try.
Sandy Smith, MEd, RHIA, CCS, the health information technology program director at Tulsa Community College, reported that one of her college’s recent graduates passed the CCS exam within several months after graduation. The graduate’s advice to those preparing to take the examination is to “buy as many coding workbooks as you can afford and code everything you can find, even from different registering agencies.
“Coding is the only way to build up speed,” the graduate said. “And don’t believe all the answers. Look them up in the references that are listed to see if the author is correct.”
Keeping Up on Coding Clinic, CPT Assistant Content
One area of the exam listed on the CCS Examination Content Outline is to select the appropriate diagnosis and procedure codes according to the Coding Clinic and CPT Assistant, and according to UHDDS definitions. Therefore, coders should become familiar with these resources. Several sources suggest that test-takers familiarize themselves with the last three to five years’ worth of material. Others choose to study only the last one to two years’ worth of material.
OkHIMA has recently taken the lead in this area and plans to offer quarterly Coding Clinic Update workshops. Members in the Tulsa and Oklahoma City area will receive education from this publication and will have the opportunity to ask questions and receive feedback from an instructor and other participants. OkHIMA has been proactive in offering education, evident in their selection as the AHIMA Core Services Achievement Winner in 2013 for their commitment to continuing education programs relating to HIM practice topics.
Benefits of keeping up with each Coding Clinic and CPT Assistant go far beyond preparation for the CCS exam. “Given that Coding Clinic is official advice used by outside regulators to challenge query and coding appropriateness, CDI specialists and coders alike must familiarize themselves with its logic in order to successfully defend their coded output,” says James Kennedy, MD, CCS, director of FTI Healthcare, based in Atlanta, GA. Kennedy says that ignoring the two publications is a big mistake.
Improvement Opportunities Exist for Test-Takers and Test Encouragers
Even though ICD-10 is not a part of the CCS exam now, the exam will test using ICD-10 upon its official implementation for reporting and billing in the US. Coders must be proactive in gaining ICD-10 knowledge and skills, despite their ICD-10 fear and unfamiliarity, in order to take and pass the CCS exam in the future. State associations, workplaces, and possibly educational institutions also have opportunities to host ICD-10 workshops, Coding Clinic and CPT Assistant workshops, CCS exam review courses, and inpatient/outpatient cross-training webinars for their employees and students to help them gain the knowledge, experience, and confidence needed to successfully pass the CCS examination. Coders can also “own” their certification journey by subscribing to coding publications and newsletters, like AHIMA’s CodeWrite, where certification preparation information can be found, and participating in the AHIMA Engage Certification Preparation Communities of Practice for further support and resources.
Follow these and the other recommended steps, and coders will feel more comfortable sitting for the examination—and hopefully successfully pass it.
AHIMA. “CCS Recommended Resources.” www.ahima.org/~/media/AHIMA/Files/Certification/CCS_Recommended_Resources.ashx.
AHIMA. “Certified Coding Specialist (CCS) Examination Content Outline.” www.ahima.org/~/media/AHIMA/Files/Certification/ICD-10%20CCS%20Content%20Outline.ashx.
AHIMA. “Certification Examination Preparation.” www.ahima.org/certification/CCS.
HCPro. “Tip: Stay up to date with quarterly Coding Clinic releases.” CDI Strategies. October 1, 2009. www.hcpro.com/HIM-239829-5707/Tip-Stay-up-to-date-with-quarterly-Coding-Clinic-releases.html.
Kelli Horn (firstname.lastname@example.org) is the coding education manager at Ardent Health Services and an AHIMA-approved ICD-10-CM/PCS trainer. Horn is also an author, conducts CCS examination review courses for OkHIMA, ArHIMA, and NYHIMA, and is an adjunct coding instructor at Tulsa Community College.
"Top Ten Challenges of Passing the CCS Examination (And How to Overcome Them)"
Journal of AHIMA