Your FREE CCS Flashcards 2026 – 200+ Cards

The third character of an ICD-10-PCS code — the objective of the procedure (e.g., Excision, Resection, Bypass).

The U.S. clinical-modification code set for reporting diagnoses in all health-care settings.

The 7-character code set used to report inpatient hospital procedures.

Current Procedural Terminology — the AMA code set for physician and outpatient procedures and services.

Codes for supplies, drugs, equipment, and services not covered by CPT.

The condition established after study to be chiefly responsible for the patient's admission to the hospital (UHDDS definition).

In outpatient coding, the diagnosis or reason chiefly responsible for the services provided, sequenced first.

Means the principal diagnosis is the condition the workup confirms caused the admission — not the admitting diagnosis or chief complaint.

An additional condition that affects patient care during the encounter (a comorbidity or complication).

The order codes are listed: the principal/first-listed diagnosis first, then secondary diagnoses and procedures.

Always exactly 7 characters; each position has a fixed meaning that is independent of the others.

Section — where the procedure is performed (e.g., 0 = Medical and Surgical).

Body system — the general body system involved.

Root operation — the objective of the procedure (most-tested PCS character).

Body part — the specific anatomical site.

Approach — the technique used to reach the site (Open, Percutaneous, etc.).

Device — any device that remains after the procedure (Z = no device).

Qualifier — additional detail unique to the procedure (Z = none).

Cutting out or off, without replacement, a PORTION of a body part.

Cutting out or off, without replacement, ALL of a body part.

Excision removes part of a body part; Resection removes all of it (e.g., total nephrectomy = Resection).

Eradicating all or a portion of a body part by direct energy, force, or a destructive agent.

Pulling or stripping out all or a portion of a body part by force.

Cutting off all or a portion of an extremity — i.e., amputation.

Altering the route of passage of the contents of a tubular body part.

Taking or letting out fluids and/or gases from a body part.

Putting in a non-biological device that monitors, assists, performs, or prevents a function but does not take the place of a body part.

Putting in biological or synthetic material that physically takes the place of all or a portion of a body part.

Cutting through skin or mucous membrane and any other layers to fully expose the procedure site.

Entry by puncture or minor incision of instrumentation to reach the procedure site.

Entry by puncture or minor incision of instrumentation AND visualization to reach and see the site.

A two-character CPT/HCPCS addition that gives extra detail about a service (e.g., bilateral, distinct, repeat).

Distinct procedural service — indicates a procedure was separate and distinct from others performed the same day.

Bilateral procedure — the same procedure was performed on both sides.

Professional component — reports only the physician's interpretation portion of a service.

Medicare Severity Diagnosis-Related Group — the inpatient classification that pays a fixed amount per admission.

Complication or comorbidity — a secondary condition that increases resource use and can raise the DRG tier.

Major complication or comorbidity — a secondary condition that increases resource use even more, often shifting to a higher DRG.

An MCC raises the DRG (and payment) more than a CC; both depend on complete documentation of secondary diagnoses.

Ambulatory Payment Classification — the payment unit under Medicare's hospital Outpatient PPS.

Inpatient Prospective Payment System — pays acute hospitals a fixed amount per MS-DRG.

Outpatient Prospective Payment System — pays hospitals for outpatient services using APCs.

DRGs pay for inpatient admissions (IPPS); APCs pay for hospital outpatient services (OPPS).

Present on Admission — a value (Y, N, U, W) reported with each inpatient diagnosis showing whether it was present at admission.

The condition was present at the time of inpatient admission.

The condition was not present at the time of inpatient admission.

Documentation is insufficient to determine whether the condition was present on admission.

The provider is unable to clinically determine whether the condition was present on admission.

National Correct Coding Initiative edits — automated checks that prevent improper code pairs and unbundling.

Extracting and recording the relevant data (diagnoses, procedures, demographics) from the record for coding and reporting.

Rules in the code book — Alphabetic Index, Tabular List, includes/excludes notes, 'code first' and 'use additional code.'

An ICD-10-CM instruction to sequence an underlying condition before the manifestation code.

An ICD-10-CM instruction to add a secondary code to fully describe a condition.

ICD-10-CM convention meaning the two conditions cannot be coded together (a 'not coded here' rule).

ICD-10-CM convention meaning the condition is not part of the code but both may be reported together if present.

A single ICD-10-CM code that classifies two diagnoses, or a diagnosis with a manifestation or complication.

ICD-10-CM specificity for the side of the body (right, left, bilateral) required for many conditions.

ICD-10-PCS.

CPT and HCPCS Level II.

ICD-10-CM.

The principal diagnosis, procedures, and the presence of any CC or MCC.

Resource-Based Relative Value Scale — the basis of the Medicare physician fee schedule, paying per relative value unit (RVU).

Patient-Driven Payment Model — the case-mix-adjusted per-diem payment system for skilled nursing facilities.

Evaluation and Management coding — CPT codes for office, hospital, and other patient-management visits.

An encoder is software that helps assign codes; the code book is the printed reference — both must follow the Official Guidelines.

An MCC is a secondary diagnosis, so it is never the principal diagnosis — but it can move the case to a higher DRG.

It drives the Hospital-Acquired Condition payment policy: a complication not present on admission may not raise the DRG.

ICD-10-CM rule to code the underlying condition (etiology) first, then the manifestation, often with paired codes.

Codes for signs and symptoms are not assigned when a related definitive diagnosis has been established.

When both acute and chronic forms are documented and indexed separately, code both, sequencing the acute first.

If it occurred, code it as a confirmed diagnosis; if it did not, follow the index for 'impending' or 'threatened.'

For inpatients, an uncertain diagnosis (probable, suspected, likely) documented at discharge is coded as if it exists.

For outpatients, uncertain diagnoses are NOT coded; code the documented signs, symptoms, or reason for the visit.

An ICD-10-CM code for factors influencing health status and contact with health services (not a disease).

ICD-10-CM codes describing how an injury or condition happened; never sequenced as a principal diagnosis.

Code the underlying systemic infection first; severe sepsis requires a code for sepsis plus the associated organ dysfunction.

The procedure performed for definitive treatment, or most related to the principal diagnosis, sequenced first among procedures.

Certain ICD-10-CM codes (e.g., some Z codes) are exempt from POA reporting per the official list.

Five-digit CPT codes for widely performed procedures and services with FDA approval where applicable.

Optional CPT tracking codes for performance measurement (alphanumeric, ending in F).

Temporary CPT codes for emerging technology, services, and procedures (alphanumeric, ending in T).

Significant, separately identifiable E/M service by the same provider on the day of a procedure.

Multiple procedures performed at the same session by the same provider.

Repeat procedure or service by the same physician on the same day.

A single CPT payment covering the procedure plus normal pre- and post-operative care for a defined period.

HCPCS Level II codes for drugs administered other than orally (e.g., injectables).

APR-DRG concepts that adjust inpatient classification based on how sick the patient is and mortality risk.

The average DRG relative weight for a facility — reflects the resource intensity of its patients.

A number reflecting the average resources to treat cases in a DRG relative to the average inpatient case.

The ICD-10-CM code listed next to the main term in the Alphabetic Index, representing the most common form.

A condition or procedure named after a person (e.g., a disease name); look it up under the eponym or the condition.

NEC = not elsewhere classifiable (specific info exists but no code); NOS = not otherwise specified (unspecified).

An ICD-10-CM placeholder (X) used to fill empty positions so a required 7th character lands correctly.

An extension required for certain categories (e.g., injuries) indicating encounter type: initial, subsequent, or sequela.

A residual condition produced after the acute phase of an illness or injury has ended; code the condition, then the sequela code.

An ICD-10-PCS resource that maps anatomical terms to the correct PCS body-part value.

An ICD-10-PCS resource that maps device terms to the correct PCS device value (character 6).

Every code must be supported by documentation in the body of the health record.

Query the provider — never choose one diagnosis or assume which is correct.

Confirm that the documentation in the record actually supports each assigned code.

Efforts to ensure the record accurately and completely reflects the patient's clinical status to support correct coding.

Documentation that is unclear; the coder queries for clarification rather than guessing.

Documentation missing the detail needed to assign a code; the coder queries for specificity.

Documentation where clinical indicators don't match the stated diagnosis; the coder queries.

Two providers (or notes) state different diagnoses, admission types, or laterality; resolved only by clarification.

No — a coder cannot assign a diagnosis the provider has not documented; the record must be clarified.

The official business record of patient care; codes must be supported by, and queries documented in, this record.

The operative or procedure report — coders read it to assign the correct ICD-10-PCS code.

A summary of the inpatient stay used to confirm diagnoses, procedures, and the principal diagnosis.

The admission documentation of the patient's history and exam; part of the record the coder reviews.

Only after the provider's clarification is entered into the record can the coder assign the code.

Required documentation must appear in the record itself, not only on a cover sheet or claim.

When documentation disagrees on admission type, the coder queries to resolve it before coding.

When the side of the body is documented inconsistently, the coder queries to clarify before coding.

The provider documents the diagnosis; the coder ensures the documentation supports the assigned code.

The coder assigns the code with confidence — no query is needed.

Incomplete documentation can cause missed CCs/MCCs, wrong DRGs, denials, and compliance risk.

Only the provider may amend or clarify clinical documentation — never the coder.

The documentation must show why a service was needed so the diagnosis can support the procedure billed.

Used when documentation lacks the detail (e.g., type, acuity, site) needed to assign the most specific code.

Generally diagnoses are coded from provider documentation; some clinical details (e.g., BMI, stage) may come from other clinicians if the provider documents the condition.

Abnormal lab or test findings are not coded unless the provider documents their clinical significance.

CDI aims for an accurate record; any resulting reimbursement change must follow from accuracy, not the other way around.

Coders review the entire record (H&P, progress notes, op reports, diagnostics, discharge summary) before final coding.

When the attending and a consultant disagree, query the attending (the provider responsible for the diagnosis).

Records must be completed timely; coding waits for required documentation rather than guessing.

A communication asking a provider to clarify ambiguous, incomplete, conflicting, or clinically inconsistent documentation.

A non-leading query supported by clinical indicators that does not suggest a diagnosis solely to increase reimbursement.

A non-compliant query that steers the provider toward a particular answer, usually to maximize payment.

Documented signs, symptoms, lab values, treatments, or findings that justify and support a query or diagnosis.

When documentation is ambiguous, incomplete, conflicting, or clinically inconsistent.

A compliant query offers balanced, clinically supported choices plus 'other' and 'clinically undetermined.'

A query may only clarify the record; writing it to increase payment makes it leading and non-compliant.

Into the legal health record — it must be documented there before the code is assigned.

To clarify documentation so the correct code can be assigned — not to question clinical judgment.

Both are acceptable if compliant; a verbal query and its response must still be documented.

Analyzing current documentation to spot where indicators support a diagnosis the provider hasn't stated.

Low serum sodium plus hypertonic saline but no stated diagnosis — query for possible hyponatremia.

Presents the clinical facts neutrally and asks the provider to interpret, rather than naming the answer.

When indicators don't support a documented diagnosis, a query can also confirm whether it should stand.

A coder cannot add, change, or assume a diagnosis — only the provider can resolve the query.

Queries must follow AHIMA/industry guidance: compliant, non-leading, and clinically supported.

A compliant format offering reasonable, clinically supported options plus 'other' and 'unable to determine.'

A compliant format asking the provider to document the diagnosis in their own words, prompted by clinical indicators.

Queries and their responses are part of the documentation/compliance trail and are retained per policy.

A query may be needed to clarify whether a condition was present on admission for POA reporting.

A query can address whether a documented diagnosis is clinically supported by the indicators in the record.

The Health Insurance Portability and Accountability Act, protecting health information via its Privacy and Security Rules.

Individually identifiable health information protected under HIPAA.

The HIPAA principle of using or disclosing only the least PHI needed to accomplish the purpose.

Limits how PHI is used and disclosed and gives patients rights to access and control their information.

Sets standards to protect electronic PHI (ePHI) through administrative, physical, and technical safeguards.

Treatment, payment, and health-care operations (TPO) are permitted; most other uses require authorization.

Uniform Hospital Discharge Data Set — standardized inpatient data elements, including the principal-diagnosis definition.

Professional principles requiring accurate, complete, honest coding that reflects the documentation — never upcoding.

Assigning a code for a more severe or expensive condition or service than the documentation supports — fraud.

Reporting components of a service separately for higher payment when one combined code applies.

Patient Safety Indicator — an AHRQ measure that screens coded data for potentially preventable in-hospital complications.

Hospital-Acquired Condition — a reasonably preventable condition acquired during the stay.

Under CMS policy, a HAC that was not present on admission can reduce Medicare payment.

Certain surgical-site infections, falls with injury, and catheter-associated urinary tract infections.

A service must be reasonable and necessary to diagnose or treat a condition; the diagnosis must support the procedure billed.

Individual payers have their own coverage and coding rules a coder must follow beyond the Official Guidelines.

Fraud is intentional deception for gain (e.g., upcoding); abuse is improper practices that result in unnecessary cost.

An organizational system of policies, audits, and education designed to prevent coding fraud and abuse.

A regulatory-compliance task: confirming the record is complete and accurate before final coding.

It protects patients, the organization's integrity, and reimbursement accuracy, and avoids audits and penalties.

Code only what the documentation supports; never choose an option just because it pays more.

Office of Inspector General — investigates health-care fraud and publishes compliance guidance and work plans.

Under HIPAA, patients have the right to access and obtain a copy of their own health information.

An impermissible use or disclosure of PHI; HITECH added breach-notification requirements.

Health plans, health-care clearinghouses, and providers who transmit health information electronically.

Treatment, Payment, and health-care Operations — the HIPAA-permitted disclosures that do not require authorization.

Health information stripped of identifiers so it is no longer PHI and falls outside HIPAA restrictions.

Recovery Audit Contractor — reviews Medicare claims to identify and recover improper payments.

A federal law imposing liability for knowingly submitting false or fraudulent claims to the government.

Following UHDDS definitions and data elements is a Regulatory Compliance task for inpatient reporting.

A claim denied because the diagnosis did not support the medical necessity of the service billed.

Apply accurate codes, query when needed, refuse to misrepresent conditions, and report compliance concerns.

A review of coded records against documentation to verify accuracy and compliance; supports the compliance program.

Electronic Health Record — a digital version of a patient's chart maintained over time by providers.

Software that helps a coder find and assign correct ICD-10/CPT/HCPCS codes, often with built-in references and edits.

Software that classifies a coded case into a payment group such as an MS-DRG or APC.

An encoder helps assign codes; a grouper turns the assigned codes into a payment classification.

Software using natural-language processing to suggest codes from documentation; a coder must validate every code.

CAC suggestions can be wrong or incomplete, so a credentialed coder must review, correct, and finalize them.

The Health Information Technology for Economic and Clinical Health Act — promoted EHR adoption and strengthened HIPAA.

HIPAA sets the privacy and security rules; HITECH strengthened their enforcement and pushed EHR adoption.

Technology that reads free-text documentation to identify codable concepts for CAC.

No — encoders, groupers, and CAC assist, but the credentialed coder's judgment remains essential.

Structured (coded fields) and unstructured (free-text notes); CAC works on the unstructured text.

A vendor handling PHI for a covered entity; HITECH extended HIPAA obligations to business associates.

HITECH requires notifying affected individuals (and HHS) when unsecured PHI is breached.

CAC can speed coding and improve consistency, but accuracy still depends on coder validation.

The EHR is the source documentation the coder reviews to assign and validate codes.

The ability of different health IT systems to exchange and use information, supported by EHR standards.

Documentation → NLP suggests codes → credentialed coder reviews/validates → final codes assigned.

CMS programs that incentivized EHR adoption and data exchange under HITECH.

Coded, discrete EHR fields (e.g., problem lists) that support reporting and analytics.

A database that maintains a unique identifier for each patient across an organization's systems.

EHR tools that provide alerts and guidance to clinicians at the point of care.

A record of who accessed or changed the EHR and when — supports HIPAA security and accountability.