Medical Billing and Coding Certification

Available Certifications for Medical Coders

Over 70,000 medical billers and coders nationwide hold certifications from the American Association of Professional Coders. These certifications validate an individual’s comprehension of various specializations within medical billing and coding. Although it’s possible to obtain a job as a medical biller or coder without these types of credentials, those who obtain them experience massive benefits:

• AAPC certifications are recognized across the nation by governmental bodies, medical societies and employers.
• Average salaries are around 20% higher for those with proper credentials.

CPC – Certified Professional Coder

When you receive the CPC credential, you prove to employers and governmental agencies that you have a broad comprehension of the procedures necessary to review and assign the correct coding of physician diagnoses, procedures and services for medical claims. As you train for a CPC credential, you’ll learn how to:

• Assign medical codes based on operative reports and coding guidelines.
• Apply billing reimbursement.
• Correctly use medical terminology.
• Understand human anatomy and physiology as they relate to coding provider services and diagnoses.
• Handle issues related to reimbursement and compliance, including charge capture, bundling issues, claims denials and medical necessity.
• Integrate rule changes related to reimbursement and medical coding into current work practices.

Who Needs the CPC Credential?

You should seek the CPC credential if you plan to work as a medical coder in a:

• Physician billing service
• Physician group or office
• Compliance or forensic auditing center
• Home health agency
• Health system-associated office
• Hospital-associated office
• Outpatient hospital not reimbursed by APC (Ambulatory Patient Category) groups
• Ambulatory Surgery Center, or ASC

You might also find the CPC medical coding certification useful if you’re a physician, legal counselor, educator or consultant looking to prove your understanding of medical coding in an outpatient setting.

How Do You Get the CPC Credential?

Obtaining the CPC credential requires taking and passing the CPC examination administered by the AAPC. This exam covers a variety of topics, including:

• ICD-9-CM diagnosis codes, which are used to bill medical services to CMS (Centers for Medicare and Medicaid Services) and insurance companies.
• HCPCS (Healthcare Common Procedure Coding System) Level II supply and procedure codes.
• The correct applications of Current Procedural Terminology (CPT).

Specifically, one’s knowledge of the following will be tested:

• Anatomy and Physiology
• Anesthesia
• Coding Guidelines
• Digestive System
• Endocrine System
• Evaluation and Management
• Eye and Ocular Adnexa
• HCPCS Level II
• Hemic and Lymphatic Systems
• ICD-9-CM
• Integumentary System
• Male and Female Genital Systems
• Maternity and Delivery
• Mediastinum and Diaphragm
• Medical Terminology
• Medicine
• Musculoskeletal System
• Nervous System
• Pathology
• Practice Management
• Radiology
• Respiratory System
• Urinary System

Other CPC Credentialing Requirements

Aside from taking and passing the CPC exam, you’ll need to a complete a few objectives in order to attain and maintain certification as a CPC. These include:

• Completing an associates degree. Note that this is recommended but not required. Accredited associates degree programs in areas such as medical billing and coding and health information processing should provide you with the skills and knowledge necessary to pass the exam.
• Paying an exam fee when you submit your application.
• Becoming a member of the American Association of Professional Coders. If you’re not a member yet, you’ll need to become one by paying a membership fee when you submit your application. Your membership will need to be active at two crucial points: when you submit the application and when the results of your exam are released.
• Obtaining two years of professional medical coding experience.
• Completing 36 CEUs (Continuing Education Requirements) every two years.

You might be wondering – “how can I complete the two-year professional experience requirement if I haven’t yet received my CPC credential?” There are two answers to this question. First, there are plenty of entry-level employment opportunities available to those who aren’t credentialed. Second, you can receive pre-credentialing from the AAPC in the form of an Apprentice designation. As such, you’ll have the credential of CPC-A (Certified Professional Coder – Apprentice) immediately after passing the exam, regardless of your work history.

Ironically, the goal of all individuals with a CPC-A certification is to drop the Apprentice designation from their titles. You can do this using two different methods:

1. Obtaining at least 80 hours of education in coding and submitting a letter of recommendation (printed on letterhead) written by your employer. The letter must verify at least one year of professional experience using HCPCS, ICD-9-CM or CPT code sets. You can verify completion of the education requirement by submitting a school transcript, a diploma showing 80 or more contact hours, or a letter of recommendation (again, printed on letterhead) written by your professor. Make sure that the professor states the number of contact hours you’ve completed in the letter.
2. Submitting two letters of recommendation indicating that you’ve completed two years of professional experience using HCPCS, ICD-9-CM or CPT code sets. One of the letters must be printed on letterhead and must originate from your employer. The letters should be typed, signed, and detailed in regards to your work responsibilities and how long you’ve been employed. The AAPC offers a template that you can download and give to your employer to expedite the process. As always, this letter must be printed out on letterhead.

Quick Stats About Medical Billing and Coding Certification Exams

Regardless of the medical coding credential you plan to pursue, the pathway to certification always involves an examination. While different exams cover different areas of study, they have a few features in common as well. Here are some of the most important:

• Most exams consist of 150 questions.
• The questions are delivered in a multiple choice format.
• You’ll have a maximum of 5 hours and 40 minutes to complete the exam.
• Exam fees start at under $300, and discounts are often available for AAPC members.
• You can retake the exam for free, but only once. You’ll need to pay again if you don’t pass after your second attempt.
• The exam is open-book, but only certain materials are allowed.

CPC-H – Certified Professional Coder – Outpatient Hospital

When you receive the CPC-H credential, you prove that you can accurately code for outpatient facilities and hospital services. This involves the use of ICD-9-CM diagnosis codes, HCPCS Level II supply and procedural codes and CPT. Successful CPC-Hs can explain why certain codes are used over others and adjudicate the coding and billing of procedures, diagnoses and services in outpatient settings. As you pursue the CPC-H credential, you’ll learn how to:

• Complete a UB04 while appropriately applying modifiers.
• Understand how medical terminology, human physiology and human anatomy directly relate to correctly coding diagnoses and provider services.
• Understand how to assign ICD-9-CM codes using AHA Coding Clinic guidelines.
• Integrate reimbursement and coding rule changes, such as Field Locators, fee updates and CDM (Charge Description Master).
• Understand issues including charge capture, claims denials, medical necessity and bundling issues as they relate to compliance, reimbursement and coding within outpatient systems.
• Accurately assign medical codes for services, procedures and diagnoses in outpatient settings.

Who Needs the CPC-H Credential?

You should seek the CPC-H medical billing and coding certification if you plan to work in one of the following situations or settings:

• Ambulatory Surgical Centers
• Auditing facilities dealing with outpatient service coding and billing
• Hospital outpatient coding and billing departments
• Billing APCs (Ambulatory Patient Category) for outpatient services
• Administering utilization reviews for hospital outpatient services

The CPC-H certification is also useful for legal counselors, physicians, consultants, educators and any caregivers looking to prove their comprehension of outpatient medical coding in hospital environments.

How Do You Get the CPC-H Credential?

The CPC-H credential can be obtained by taking the CPC-H examination. This exam tests your ability to correctly apply ICD-9-CM diagnosis codes, CPT codes, and HCPCS Level II supply and procedure codes when coding and billing insurance companies for outpatient hospital services. The following topics are covered in this exam:

• Compliance
• Surgery and Modifiers
• Code Assignment ICD-9-CM
• CPT
• HCPCS Level II
• Coding Guidelines
• Anatomy
• Medical Terminology
• Payment Methodologies

Other CPC-H Credentialing Requirements

Aside from the examination itself, credentialing requirements for the CPC-H certification are the same as those for the CPC certification. Note that the CPC-H exam results report your three weakest areas in addition to exact scores.

CPC-P – Certified Professional Coder – Payer

By obtaining the CPC-P, you’ll prove your knowledge of and proficiency in reimbursement methodologies and coding guidelines for a variety of services from the prospective of the payer as well as the medical services provider – something that many medical billers and coders rarely even consider. As you pursue the CPC-C certification, you’ll learn how to:

• Understand the relationships between payment and coding functions.
• Understand how provider coding differs from payer functions.
• Perform the same tasks expected of those with the CPC certification.

Who Needs a CPC-P Credential?

It’s wise to seek the CPC-P certification if you work in or plan on working in one of the following situations or settings:

• Customer service
• Billing services
• Utilization review
• Auditing a payer
• Performing post-billing auditing for a physician facility or group
• Performing claims management for a payer, such as Medicaid, Medicare or a private insurance company

You might also seek the CPC-P credential if you’re an educator, consultant, physician, legal counselor or any caregiver looking to prove your understanding of how medical coding works in a payer setting.

How Do You Get the CPC-P Credential?

Taking the CPC-P examination allows one to obtain the CPC-P credential. This exam includes two separate sections:

1. Reimbursement Methodologies
2. Medical Coding Concepts

The Reimbursement Methodologies portion covers topics such as HIPAA, health insurance concepts, outpatient and inpatient payment systems, and physician reimbursement. The Medical Coding Concepts portion tests your understanding of coding using ICD-9-CM, HCPCS Level II and CPT, as well as human anatomy and medical terminology.

Other Certification Requirements

Aside from the fact that those pursuing the CPC-P certification must take the CPC-P exam, the other certification requirements (work experience, fees, etc.) are the same as those for the CPC credential.

What You Can and Can’t Use During Medical Coding Certification Exams

The good news is that most medical coding certification exams allow you to bring in some reference materials. The bad news is that many of the most popular books and manuals are banned from use. Here are a few references that you’re free to have at your side during the exam:

Reference Material	Allowed	Not Allowed
Any HCPCS Level II Manual	X
Any ICD-9-CM Manual	X
Professional and AMA Standard Editions of CPT Books	X
ICD-9-CM Easy Coder – Unicor		X
Current Procedural Coding Expert by Ingenix		X
CPT Plus! by PMIC		X
Procedural Coding Professional by AAPC		X
Procedural Coding Professional by Contexo		X
Coders’ Choice CPT by PMIC		X
Procedural Coding Expert by AAPC		X
Procedural Coding Expert by Contexo		X
CPT Insider’s View by AMA		X

CIRCC – Certified Interventional Radiology Cardiovascular Coder

There’s a growing demand in the medical field for individuals specializing in Interventional Radiology Cardiovascular. As such, the AACP is now offering the CIRCC credential, created with input from expert billers, coders, technicians and physicians in the IRC field. Error rates have been notoriously high in this subspecialty of radiology, further increasing the need for more knowledgeable experts who understand cardiovascular and radiology charging and coding.

Who Needs the CIRCC Credential?

You’ll want to consider pursuing a CIRCC credential if you work or plan to work in one of the following settings:

• Angio suites
• Interventional radiology departments
• Endovascular suites
• Operating rooms
• Cardiac cauterization labs
• Any other clinics or departments practicing non-vascular intervention

The CIRCC credential is also ideal for any existing medical billers and coders who are looking to increase their salaries. According to a salary survey performed by the AAPC, CIRCCs are among the biggest earners in the medical billing and coding industry.

How Do You Get the CIRCC Credential?

One must take the CIRCC examination administered by the AAPC in order to get the CIRCC credential. This exam covers the following topics:

• Medical Terminology
• Human Anatomy
• Basic Medical Coding
• Coronary Arterial Interventions
• Percutaneous Vascular Interventions
• Non-vascular interventions including spine interventions, ablations, biopsies, biliary procedures, etc.
• Diagnostic angiography
• Diagnostic cardiac cauterization

Percutaneous vascular interventions, non-vascular interventions and diagnostic angiography each make up around 25% of the CIRCC exam. Another 10% is devoted to basic coronary arterial interventions and diagnostic cardiac catheterization. The remainder of the test is devoted to terminology, anatomy and basic coding. You can bring anatomical charts as well as approved code manuals into this exam.

Other Certification Requirements

The certification requirements for those pursuing the CIRCC credential are the same as those associated with a CPC credential, with two very important exceptions:

1. There are no experience requirements. However, the AAPC recommends that examinees have two or more years of experience in cardiovascular and/or interventional radiology, as the exam is designed to be very difficult and comprehensive.
2. Only 24 CEUs (Continuing Education Units) are required every two years for certification renewal, as opposed to the 36 required for CPCs. These CEUs must come from three companies, exclusively: Medical Asset Management, Medical Learning, Inc., and ZHealth Publishing.

AAPC Specialty Certifications

In addition to the four aforementioned medical billing and coding certifications offered by the AAPC, the organization provides specialty credentialing in 20 different disciplines. You don’t need to be a CPC in order to obtain these certifications, though the exams leading to credentialing are very difficult, specific, and designed only for those with a deep understanding of medical billing and coding as it pertains to their areas of expertise. The specialty certifications available from the AAPC include:

• CASCC – Certified Ambulatory Surgical Center Coder
• CANPC – Certified Anesthesia and Pain Management Coder
• CCC – Certified Cardiology Coder
• CCVTC – Certified Cardiovascular and Thoracic Surgery Coder
• CCPC – Certified Chiropractic Coder
• CPCD – Certified Professional Coder in Dermatology
• CEDC – Certified Emergency Department Coder
• CEMC – Certified Evaluation and Management Coder
• CFPC – Certified Family Practice Coder
• CGIC – Certified Gastroenterology Coder
• CGSC – Certified General Surgery Coder
• CHONC – Certified Hematology and Oncology Coder
• CIMC – Certified Internal Medicine Coder
• COGBC – Certified Obstetrics Gynecology Coder
• COSC – Certified Orthopaedic Surgery Coder
• CENTC – Certified Otolaryngology Coder
• CPEDC – Certified Pediatrics Coder
• CPRC – Certified Plastics and Reconstructive Surgery Coder
• CRHC – Certified Rheumatology Coder
• CUC – Certified Urology Coder

In order to qualify for these specialty examinations, you must hold an AAPC membership, schedule the exam at least one month in advance and pay an examination fee, which is typically $245.

CASCC – Certified Ambulatory Surgical Center Coder

The CASCC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Regulatory rules according to various state and federal standards committees.
• Reimbursement rules for Ambulatory Surgical Center services, including discontinued, device-intensive and/or multiple procedures.
• The various types of surgery that may be performed at Ambulatory Surgical Centers.
• Reading and dissecting operative notes in order to apply HCPCS Level II, CPT and ICD-9-CM codes.
• Ancillary procedure codes.

CANPC – Certified Anesthesia and Pain Management Coder

The CANPC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding according to CPT, ICD-9-CM and NCCI modifiers using both 1997 and 1995 Documentation Guidelines.
• Guidelines of Medicare billing including global surgery, consultations, shared visits and teaching situations.
• Determining both total units and time units for anesthesia.
• Using common modifiers in anesthesia cases.
• Selecting CPT codes for various surgical cases and cross-walking them to the correct ASA codes.

CCC – Certified Cardiology Coder

The CCC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding various surgical procedures commonly performed by cardiologists, including peripheral vascular procedures, pacemakers, coronary interventions and hearth catheterization.
• Important regulations for Medicare billing, such as shared visits, global surgery, consultations, teaching situations and other incidents.
• Evaluation and Management using both 1997 and 1995 Documentation Guidelines.
• Reading and abstracting physician notes and operative notes in order to correctly apply codes and modifier assignments in HCPCS Level II, CPT and ICD-9-CM.

CCVTC – Certified Cardiovascular and Thoracic Surgery Coder

The CCVTC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding of the various surgical procedures commonly performed by thoracic and cardiovascular surgeons, including lung tumor ablation, PTCA and cardiopulmonary bypass.
• Regulations and rules for Medicare billing including teaching situations, global surgery, shared visits and consultations.
• Evaluation and Management according to 1997 and 1995 Documentation Guidelines.
• Applying correct HCPCS Level II, CPT and ICD-9-CM modifier codes according to physician operative notes and office notes.

CCPC – Certified Chiropractic Coder

The CCPC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding musculoskeletal, neurologic and radiologic diagnostic procedures.
• Differentiating between the different forms of manipulative procedures according to AMA standards.
• Applying CMS bundling relationships and determining appropriate users for modifier 59.
• Applying CMS and AMA rules for time-based services.
• Differentiating procedures and modalities according to descriptions of provided services.
• Making coding decisions based on the application of provided medical policy standards.
• Reading and extracting the important information from daily notations and treatment plans in order to properly code supplies provided and services performed according to supplies, ICD-9 patient diagnoses, HCPCS and CPT.
• Assessing levels and types of Evaluation and Management Services.
• Properly using modifier 25.

CPCD – Certified Professional Coder in Dermatology

The CPCD exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding surgical procedures commonly performed by dermatologists, including micrographic surgery, flaps, lesion excisions and debridement.
• Medicare billing rules and regulations pertaining to teaching situations, consultations, global surgery and shared visits.
• 1997 and 1995 Documentation Guidelines for Evaluation and Management.
• Applying physician procedure and office notes to HCPCS Level II, CPT and ICD-9-CM coding.

CEDC – Certified Emergency Department Coder

The CEDC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Time-based coding.
• Moderate sedation coding.
• Coding of the surgical procedures commonly performed by Emergency Department (ED) physicians, including foreign body removal, fracture care, laceration repair and thoracentesis.
• Medicare billing regulations and rules pertaining to global surgery, consultations, teaching situations, shared visits and other issues.
• 1997 and 1995 Documentation Guidelines for Evaluation and Management.
• Reading and abstracting physician notes in order to correctly code with HCPCS Level II, CPT and ICD-9-CM.

CEMC – Certified Evaluation and Management Coder

The CEMC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Risk assessment including topics such as missed billing opportunities, the identification of problematic situations and benchmarking.
• Time-based coding.
• Coding according to 1997 and 1995 Documentation Guidelines and CPT, ICD-9-CM and NCCI modifiers.
• Medicare billing rules and regulations including global surgery, teaching situations, consultations and shared visits.
• The three key components of Evaluation and Management, including History, Examination, and Medical Decision Making, particularly MDM and the other subjective areas found in the Documentation Guidelines.

CFPC – Certified Family Practice Coder

The CFPC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Time-based coding.
• Coding the various minor surgical procedures commonly performed by family medical practitioners, including lesion excision, fracture care and foreign body removal.
• Proper sequencing using Relative Value Units (RVUs) for coding multiple procedures.
• Coding ancillary procedures commonly performed in family medical practices, including EKGs, injections and venipuncture.
• Rules and regulations for Medicare billing issues such as global surgery, shared visits, consultations and teaching situations.
• 1997 and 1995 Documentation Guidelines for Evaluation and Management, particularly as they apply to choosing appropriate levels of service and determining levels of Medical Decision Making, Exam and History.
• Reading and abstracting physician procedural notes and office notes in order to correctly apply codes found in HCPCS Level II, CPT and ICD-9-CM.

CGIC – Certified Gastroenterology Coder

The CGIC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding the surgical procedures commonly performed by gastroenterologists, including ERCP, esophageal dilations, colonoscopies and more.
• Medicare regulations and rules pertaining to global surgery, consultations, shared visits and teaching situations.
• 1997 and 1995 Documentation Guidelines for Evaluation and Management.
• Using physician procedure and office notes to code using HCPCS Level II, CPT and ICD-9-CM code sets.

CGSC – Certified General Surgery Coder

The CGSC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding of the surgical procedures commonly performed by general surgeons, including transplants, breast procedures, hernia repairs, colonoscopies and more.
• 1997 and 1995 Documentation Guidelines for Evaluation and Management.
• Coding using operative notes and HCPCS Level II, CPT and ICD-9-CM code sets.
• Medicare billing rules and regulations pertaining to global surgery, consultations, teaching situations and shared visits.

CHONC – Certified Hematology and Oncology Coder

The CHONC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding of the surgical procedures commonly performed by oncologists, hematologists and auxiliary staff including therapeutic phlebotomies, vaccinations, venipuncture, bone marrow biopsies, bone marrow aspiration, diagnostic, therapeutic and prophylactic administration, hydration services and chemotherapy administration.
• Using physician operative notes and office notes to correctly apply codes and modifier code assignments using HCPCS Level II, CPT and ICD-9-CM code sets.
• 1997 and 1995 Documentation Guidelines for Evaluation and Management.
• Medicare billing rules and regulations regarding issues such as global surgery, NCD (National Coverage Determinations), Local Coverage Determinations (LCD), consultations, shared visits and teaching situations.

CIMC – Certified Internal Medicine Coder

The CIMC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding of the ancillary procedures commonly performed by internal medicine practitioners, including vaccinations, injections and venipuncture.
• Coding of the minor surgical procedures commonly performed in internal medicine, including skin tag removal, joint injections and trigger point injections.
• Medicare billing regulations and rules pertaining to shared visits, consultations, global surgery and teaching situations
• 1997 and 1995 Documentation Guidelines for Evaluation and Management.
• Reading and abstracting physician procedure and office notes to correctly apply coding assignments using HCPCS Level II, CPT and ICD-9-CM.

COGBC – Certified Obstetrics Gynecology Coder

The COBGC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding of the surgical procedures commonly performed by OB/GYNs, including colpopexy, biopsies and hysterectomies.
• Coding of various obstetric services including postpartum care, deliveries and antepartum care.
• Regulations and rules of Medicare billing as they apply to global surgery, consultations, teaching situations, shared visits and other issues.
• Reading and abstracting physician office and operative notes to correctly apply CPT, ICD-9-CM and HCPCS Level II codes.
• 1997 and 1995 Documentation Guidelines for Evaluation and Management.

COSC – Certified Orthopaedic Surgery Coder

The COSC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding of the surgical procedures commonly performed by orthopedists, including spine surgeries, fracture repairs and arthroscopic surgeries.
• Medicare billing regulations and rules regarding issues such as global surgery, shared visits, teaching situations and consultations.
• Coding using physician office and procedure notes along with HCPCS Level II, CPT and ICD-9-CM code sets.
• 1997 and 1995 Documentation Guidelines for Evaluation and Management.

CENTC – Certified Otolaryngology Coder

The CENTC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding of the surgical procedures commonly performed by otolaryngologists, including sinus surgeries, nasopharyngoscopies and laryngoscopies.
• Coding with HCPCS Level II, CPT and ICD-9-CM code sets based on physician operative and office notes.
• 1997 and 1995 Documentation Guidelines for Evaluation and Management.
• Medicare billing rules and regulations as they apply to consultations, global surgery, teaching situations and shared visits.

CPEDC – Certified Pediatrics Coder

The CPEDC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding of the surgical procedures commonly performed by pediatricians, including fracture care, lesion excisions and foreign body removal.
• Coding of the ancillary procedures often performed in pediatric practices, including vision testing, vaccinations, injections and venipuncture.
• Medicare billing rules and regulations regarding global periods, consultations, teaching situations and shared visits..
• Reading and abstracting physician operative notes and office notes in order to correctly apply ICD-9-CM, HCPCS Level II, CPT and modifier code assignments.
• 1997 and 1995 Documentation Guidelines for Evaluation and Management.

CPRC – Certified Plastics and Reconstructive Surgery Coder

The CPRC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding of the surgical procedures most commonly performed by reconstructive and plastic specialists, including cosmetic surgeries, facial repairs and scar revisions.
• 1997 and 1995 Documentation Guidelines for Evaluation and Management.
• Coding using CPT, ICD-9-CM and HCPCS Level II code sets along with physician procedure notes and office notes.
• Regulations and rules of Medicare billing as they pertain to global surgery, consultations, teaching and shared visits.

CRHC – Certified Rheumatology Coder

The CRHC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Coding of the surgical procedures often performed by rheumatologists, including joint injections and trigger point injections.
• Coding using physician procedure notes and office notes along with ICD-9-CM, HCPCS Level II and CPT code sets.
• 1997 and 1995 Documentation Guidelines for Evaluation and Management.
• Medicare billing rules and regulations regarding teaching situations, shared visits, global surgery and consultations.

CUC – Certified Urology Coder

The CANPC exam covers the following topics:

• Anatomy and physiology.
• Medical terminology.
• Time-based coding.
• Coding of the surgical procedures often performed by urologists, including prostactetomies, biopsies and cystoscopies.
• Coding of the ancillary procedures often performed in urology practices, including injections and urinalysis.
• 1997 and 1995 Documentation Guidelines for Evaluation and Management.
• Medicare billing rules and regulations pertaining to global surgery, consultations, shared visits and teaching situations.
• Reading and abstracting physician operative notes and office notes to correctly apply HCPCS Level II, CPT and ICD-9-CM code assignments.

Available Medical Billing and Coding Certifications from AHIMA

Similar to the AAPC, AHIMA (or the American Health Information Management Association) is a professional organization dedicated to the field of medical billing and coding. Originally founded in 1928, AHIMA contains over 61,000 members. AHIMA offers a variety of credentials that differ from those offered by the AAPC. These include:

• RHIA – Registered Health Information Administrator
• RHIT – Registered Health Information Technician
• CCS – Certified Coding Specialist
• CCS-P – Certified Coding Specialist-Physician Based
• CCA – Certified Coding Associate
• CHPS – Certified in Healthcare Privacy and Security
• CHDA – Certified Health Data Analyst

AAPC Certification vs. AHIMA Certification

At this point, you may be wondering whether it’s better to obtain a medical billing and coding certification from the AAPC or AHIMA. Keep the following points in mind when making your decision:

• Medical billing and coding certifications from both the AAPC and AHIMA are nationally recognized by employers, universities and professional organizations.
• Both organizations are extremely reputable and heavily involved in the medical billing and coding discipline.
• Some regions tend to be more favorable towards AHIMA credentials as opposed to AAPC ones, and vice versa.
• Some employers only consider applicants with credentials from the AAPC, while others only consider those certified by AHIMA. Many organizations, however, recognize credentials from both bodies.
• Some employers may be largely unaware of one organization. There have been cases of job applicants ultimately being hired after informing their prospective employers of their credentials, and explaining how both the AAPC and AHIMA are reputable credentialing bodies.
• In general, AAPC certifications are better suited to those who plan to code in physicians’ offices. AHIMA certifications are generally more appropriate for those coding in hospitals. However, both organizations transcend these generalizations by offering certain credentials. For example, AHIMA offers a CCS-P (Certified Coding Specialist – Physician-Based) credential designed specifically for those coding in physicians’ offices, while the AAPC offers a CPC-H (Certified Professional Coder – Hospital Outpatient) specifically for coders working hospitals.
• It’s entirely possible (and sometimes, a very good idea) to become certified with both organizations simultaneously.
• The AAPC offers far more specialty certifications than AHIMA.
• The topic of AAPC vs. AHIMA is hotly debated, meaning that it’s relatively easy to find insight from professional medical billers and coders via blogs and forums.

RHIA – Registered Health Information Administrator

RHIAs are essential links between patients, payers and providers. RHIAs:

• Are experts at managing medical records and patient health information by using medical classification systems, gathering and analyzing patient data, administering software information systems and using medical terminology.
• Participate in administrative committees, prepare budgets and manage both operation units and the people staffed within them.
• Possess in-depth knowledge of legal, ethical, administrative and medical standards and requirements pertaining to patient privacy and healthcare delivery.
• Use patient data to interact with the information, administrative, financial and clinical levels of organizations in order to further their daily operations.

Where do RHIAs Work?

RHIAs work in a wide variety of settings, including:

• Physician practices
• Multispecialty clinics
• Hospitals
• Ambulatory care facilities
• Mental health facilities
• Long-term care facilities
• Managed care organizations
• Insurance companies
• Pharmaceutical companies
• Educational settings
• Governmental agencies
• Consulting services
• Software vendors
• Insurance companies

How Do I Become Certified as an RHIA?

You can become an RHIA by taking the RHIA exam administered by AHIMA. This exam lasts for four hours and consists of 180 multiple choice questions. Twenty questions are considered “pretest” and are used or test evaluation purposes, while the other 160 questions are scored. Approximately 77% of those who took the RHIA exam for their first time passed in 2010. The exam costs $229 for AHIMA members and $299 for non-members. A score of at least 300 out of 400 is needed to pass this exam. The topics covered in the RHIA exam are broken down according to the following table:

30% – Organization and Management

• Managing projects.
• Managing budgets.
• Advocating for your organization, department and profession.
• Organizing meetings.
• Managing and evaluating maintenance, contract personnel and vendor contracts.
• Analyzing costs, benefits and business plans to assess resource needs.
• Analyzing budget variances.
• Managing budgets.
• Coaching and mentoring work teams.
• Managing the revenue cycle to optimize reimbursement.
• Monitoring productivity standards.
• Conducting educational activities.
• Managing human resources, including personnel issue resolution, creating job descriptions and recruiting new employees.
• Comparing organizational needs with industry trends.
• Developing operational and strategic plans for health information management across a facility.

20% – Health Data Management

• Managing health data sets and data elements.
• Developing and maintaining organizational guidelines, procedures and policies for health information management.
• Summarizing, condensing and synthesizing information in order to organize data.
• Coding procedures and diagnoses according to standardized guidelines.
• Managing the clinical data required by prospective payment systems and reimbursement systems for use in healthcare delivery.
• Managing and validating code compliance and accuracy.
• Ensuring the integrity and accuracy of health record documentation and health data.

20% – Information Technology and Systems

• Implementing and managing healthcare software applications.
• Maintaining databases through updates and data migration.
• Facilitating database design by developing data models and data dictionaries.
• Managing client-customer relationships and patient record integration.
• Evaluating administrative, clinical and special service software systems.
• Storing data and records using various mediums including electronic, paper-based and hybrid.
• Facilitating the interoperability of HIM systems by applying functional and data standards.

13% – Privacy, Security and Confidentiality

• Creating and implementing security measures to protect PHI, or Protected Health Information.
• Developing healthcare security and privacy training programs.
• Resolving problems related to healthcare security and privacy.
• Ensuring patient confidentiality by managing the use of PHI.

11% – Health Statistics and Research Support

• Querying and reporting from databases via data mining techniques.
• Analyzing and distributing information regarding risk, utilization and quality to organizational management.
• Filtering and interpreting data before it reaches the end customer.
• Responding to the data requirements of both external and internal healthcare customers.

6% – Legal and Regulatory Standards

• Preparing for licensing and accreditation processes, such as those imposed by state regulators and Medicare.
• Ensuring that an organization complies with healthcare information standards, regulations and laws.

Other Eligibility Requirements

In order to be eligible for the RHIA certification, you must graduate with a bachelor’s degree in a program in health information management from a college or university accredited by CAHIIM, or the Commission on Accreditation for Health Informatics and Information Management Education. You can prove this by submitting an official college transcript to AHIMA. You may also be eligible to take the RHIA examination if you are enrolled in your final term of study and are scheduled for graduation.

Fast Fact: Just How Important is Credentialing?

Aside from the fact that 67% of medical billers and coders say that they make more money than their non-credentialed peers (to the tune of 20% more money on average), those with certifications usually have an easier time of getting hired in the first place. In 2005, AHIMA conducted a survey of 153 of the biggest medical billing and coding employers nationwide to find out how much value they placed in the credentials of an applicant. Of these employers…

• 65% said that certified medical billers and coders require less training.
• 60% said that they produce more accurate work.
• 68% said that they improve the overall quality of healthcare delivery.
• 62% said they improve billing and reimbursement.
• 70% said that they help to reduce exposure to abuse and fraud charges.

RHIT – Registered Health Information Technician

RHITs are crucial components of the medical billing and coding process that largely specialize in quality control. RHITs:

• Use computer software to organize and analyze patient data in order to control costs and improve patient care.
• Verify the accuracy, completeness and proper entry of medical records information into computer systems.
• Code both procedures and diagnoses in patient records in order to facilitate research and reimbursement.
• Often serve as cancer registrars, in which they maintain and compile data regarding cancer patients.
• Are often promoted to management positions, typically after obtaining a bachelor’s degree.

Where do RHITs Work?

RHITs work in the following settings:

• Hospitals
• Physician practices
• Public health agencies
• Mental health facilities
• Home health agencies
• Nursing homes
• Health product vendors
• Software vendors
• Law firms
• Insurance firms
• Pharmaceutical companies

How Do I Become Certified as an RHIT?

Taking the RHIT examination administered by AHIMA allows one to become an RHIT. This exam lasts three and a half hours and consists of 150 multiple choice questions, 130 of which actually count towards your score. The RHIT exam costs $229 for AHIMA members and $299 for non-members. Of the 1,864 individuals who took the RHIT exam for the first time in 2010, 76.4% successfully passed and received their credentials. In order to pass the RHIT exam, you must achieve a minimum score of 300 out of 400. Topics tested in the RHIT exam are broken down according to the following outline:

30% – Health Data Management

Health Data Content, Structure and Standards

• Collecting and maintaining databases and data sets.
• Ensuring that health record documentation matches a diagnosis and reflects clinical findings, discharge status and progress.
• Using the appropriate terminology and clinical vocabulary to describe health information systems.
• Verifying the appropriateness, accuracy, completeness and timeliness of data sources.
• Complying with patient safety goals, particularly as they pertain to abbreviation usage.

Healthcare Information Standards and Requirements

• Ensuring that organizations comply with standards and regulations.
• Performing both qualitative and quantitative analysis on health records to ensure compliance.
• Ensuring that health records are complete, accurate and up to the standards of external regulatory bodies and organizational policies.

Clinical Classification Systems

• Finding differences between documentation and coded data.
• Using clinical health record information to verify accuracy of codes.
• Adhering to established guidelines and current regulations when assigning codes.
• Ensuring the accuracy of procedural and diagnostic groupings, including IPF, DRG and APC.
• Applying procedure codes using HCPCS Level II and CPT code sets.
• Applying procedure codes and diagnosis codes using ICD-9-CM.
• Monitoring work processes and applications in order to support coding and clinical classification.

Reimbursement Methodologies

• Supporting the accuracy of revenue cycles through coding.
• Using guidelines, such as those through LMRP (Local Medical Review Policies) and NCCI (National Correct Coding Initiative) to ensure compliance with reporting and reimbursement requirements.
• Understanding clinical data requirements as imposed by prospective payment systems and reimbursement organizations.

25% – Information Technology and Systems

Information and Communication Technologies

• Using software and hardware to ensure data gathering, analysis, storage, retrieval and reporting.
• Using email, presentation, database and spreadsheet software to execute daily work tasks.
• Using specialized software programs to complete health information management processes including release of information, medical coding, and chart management.
• Ensuring data integrity through hardware and software technology.
• Applying procedures and policies for use with Internet and intranet electronic health records, public health applications and personal health records.

Data Security

• Summarizing data gleaned from audit trails.
• Applying organizational and departmental data to informational security policies.
• Applying security and confidentiality measures to PHI, or protected health information.

Health Information Systems

• Maintaining health record retrieval and filing systems.
• Gathering and reporting data regarding incomplete health records and late-filed health records.

Data Storage and Retrieval

• Using electronic imaging technology to record and store data.
• Maintaining patient filing and numbering systems.
• Designing health record documentation tools such as computer input screens and design forms.
• Ensuring the integrity of EMPI (Enterprise Master Patient Index).
• Querying, designing and generating reports with various software programs.
• Using retrieval and archival systems to pull patient information.

17% – Health Services Delivery and Organization

Healthcare Confidentiality, Compliance and Privacy as well as Legal and Ethical Issues

• Educating staff and implementing documentation guidelines for health records.
• Preparing organizations for licensing, accreditation and certification surveys.
• Reporting compliance issues as required by organizational policies.
• Promoting ethical and legal standards of practice.
• Identifying and reporting issues related to privacy.
• Tracking disclosure of and access to patient information through user access systems and logs.
• Implementing regulatory and legal requirements pertaining to health information.

Healthcare Delivery Systems

• Knowing the roles of different disciplines and providers included in healthcare services.
• Complying with the evolving regulations of different payment systems related to healthcare, including managed care, Medicaid and Medicare.
• Complying with licensure, certification and accreditation standards imposed by both private organizations (including the Joint Commission on the Accreditation of Healthcare Organizations) and state, local and federal governments.

15% – Organizational Resources

Human Resources

• Complying with federal, state and local labor relations regulations.
• Applying ergonomics to the work process.
• Promoting positive relationships with customers.
• Assessing, reporting and improving processes through quality improvement techniques and tools.
• Prioritizing job activities and functions.
• Determining adequate coverage by performing staff analysis.
• Assessing, monitoring and reporting productivity and quality standards.
• Providing training and education to internal users of health information.
• Implementing training and orientation programs.
• Developing and conducting performance appraisals.
• Contributing to job descriptions and strategic plans pertaining to areas of responsibility.
• Leading inter- and intradepartmental teams.

Physical and Financial Resources

• Making budgeting recommendations.
• Monitoring staff, supply and equipment resources to determine workload needs.
• Recommending cost-saving ideas related to goals and work processes.
• Monitoring how coding affects the revenue cycle.

13% – Health Statistics, Quality Management and Biomedical Research

Performance Improvement and Quality Assessment

• Presenting data in both written and verbal forms.
• Participating in quality assessment programs spanning an entire organization.

Healthcare Research and Statistics

• Collecting, organizing and presenting data sets for quality management, performance improvement programs, financial reasons and administrative purposes.
• Abstracting and maintaining data for clinical registries, databases and indexes.

Other Eligibility Requirements

In order to be eligible for the RHIT examination, you must first obtain an associates degree from a health information management program accredited by CAHIIM, or the Commission on Accreditation of Health Informatics and Information Management Education. You may also take the exam if you’re currently finishing the last semester of your program and your academic records indicate that you’ll graduate. You can prove your completion of an associate’s degree by submitting official college transcripts to AHIMA.

CCS – Certified Coding Specialist

CCSs are coding experts specializing in the classification of medical data based on patient records, typically in hospital settings. CCSs:

• Possess a thorough understanding of pharmacology, disease processes and medical terminology.
• Fully comprehend the CPT and ICD-9-CM code sets.
• Accurately assign numeric codes for various procedures and diagnoses based on patient medical records.

Where do CCSs Work?

CCSs commonly work in the following settings:

• Hospitals
• Insurance companies
• Governmental agencies
• Public health agencies
• Physicians offices

How Do I Become Certified as a CCS?

You can become a certified CSS by taking the CCS examination administered by AHIMA. This exam lasts for a total of four hours and is divided into two parts. Part 1 includes 60 multiple choice questions, 50 of which count towards your score. Part II is devoted to medical record coding and asks you to accurately code 13 medical records. These include 7 outpatient records and 6 inpatient records. The outpatient records are divided into Pain Management/Interventional Radiology/Cardiac Cath (2), emergency room (1) and ambulatory surgery (4). The CPT code set is used for coding ambulatory care procedures. Volumes 1 and 2 of ICD-9-CM are used to code ambulatory care diagnoses. Volumes 1, 2 and 3 of ICD-9-CM are used to code inpatient procedures and diagnoses.

The CCS exam costs $299 for AHIMA members and $399 for non-members. A total of 1837 individuals took the CCS exam for the first time in 2010. Of these individuals, 48.5% passed and received their CCS credentials. This exam has a first-time test taker failure rate higher than any other AHIMA exam aside from the CHPS exam. In order to pass the CCS exam, you must receive a score of at least 30 out of 50 on the multiple choice section and 223 out of 340 on the coding section. The CCS exam outline breaks down as follows:

20% – Diagnosis Coding

• Coding diagnoses based on reporting and coding requirements for both outpatient and inpatient services.
• Interpreting tables, instructional notations, formats, definitions and conventions of classification systems in order to code reasons for medical visits, conditions and diagnoses.
• Applying ICD-9-CM code set guidelines.
• Sequencing reasons for medical visits, such as diagnoses, according to the conventions and guidelines of standard data sets and classification systems.

20% – Procedure Coding

• Applying official HCPCS Level II, ICD-9-CM and CPT coding guidelines.
• Using conventions and notations of standard data sets and classification systems in order to sequence procedures.
• Interpreting definitions, instructional notations, formats and conventions of classification systems in order to code services and procedures.
• Coding procedures based on coding and reporting requirements pertaining to both inpatient and outpatient services.

15% – Health Information Documentation

• Interpreting health record documentation through an understanding of medical terminology, pharmacology, clinical disease processes, physiology and anatomy in order to correctly code procedures and diagnoses.
• Determining when additional documentation is required in order to properly assign codes.
• Consulting with physicians and reference materials in order to obtain additional documentation.
• Identifying various patient encounter types.
• Using documentation to accurately bill for provided healthcare services.

10% – Reporting Requirements and Regulatory Guidelines for Inpatient Services

• Assigning appropriate discharge dispositions.
• Using IPPS (Inpatient Prospective Payment System) definitions to verify DRG (Diagnosis Related Group) assignments.
• Evaluating how DRG assignments impact code selection.
• Using ICD-9-CM to code comorbid conditions, complications, principal procedures and diagnoses, and other procedures and diagnoses.

10% – Reporting Requirements and Regulatory Guidelines for Outpatient Services

• Applying OPPS (Outpatient Prospective Payment System) reporting requirements pertaining to Evaluation and Management, medical necessity, HCPCS Level II, CPT and modifier codes.
• Using HCPCS Level II, ICD-9-CM, CPT and UHDDS code definitions to correctly code primary procedures, pertinent secondary conditions, reasons for encounters and other procedures.

8% – Data Quality and Management

• Assessing the quality and accuracy of coded data.
• Assessing the completeness and quality of coding by analyzing health record documentation.
• Ensuring the accuracy of data elements for claims processing and database integrity.
• Resolving coding edits using OCE (Outpatient Code Editor), MCE (Medicare Code Editor) and CCI (Correct Coding Initiative).
• Educating healthcare providers on issues including coding regulations, documentation rules and reimbursement methodologies.

6% – Confidentiality, Privacy, Ethical and Legal Issues

• Recognizing and reporting privacy problems to proper authorities.
• Applying the AHIMA Standards of Ethical Coding and Code of Ethics.
• Protecting data validity and integrity through hardware and software technology.
• Applying organizational procedures and policies to determine the proper disclosure of and access to patient health information.

6% – Compliance

• Ensuring compliance with coding guidelines and rules by developing organization-wide coding policies.
• Using both external standards and guidelines and organizational policies to ensure the completeness and accuracy of patient medical records.
• Maintaining and monitoring compliance with nationwide coding guidelines and organization-wide documentation guidelines.
• Recognizing and reporting compliance issues to the proper authorities.

5% – Communication and Information Technologies

• Using specialized software to complete health information management processes.
• Using basic software applications such as email, spreadsheets and word processors to execute daily job tasks.
• Using computers to collect, analyze, store and report data.

Other Eligibility Requirements

In order to be eligible for the CCS credentialing exam, you must have at least a high school diploma from a school located in the US, or an equivalent educational background (such as a GED). In addition, it is recommended that prospective CCS applicants first complete coursework in pharmacology, pathophysiology, anatomy and physiology. AHIMA also recommends that CCS applicants have three or more years of professional coding experience in inpatient and/or outpatient medical billing and coding.

CCS-P – Certified Coding Specialist-Physician Based

CCS-Ps are coding practitioners specializing in outpatient coding. CCS-Ps:

• Review patient medical records in order to assign various numeric codes to procedures and diagnoses.
• Specialize in health information data integrity, quality and documentation.
• Allow health providers to receive reimbursement from the government and insurance companies for the services they provide, based on coded data.
• Possess a comprehensive understanding of the CPT code set and a strong familiarity with HCPCS Level II and ICD-9-CM code sets.

Where do CCS-Ps Work?

CCS-Ps work in the following settings:

• Physician offices
• Specialty centers
• Multi-specialty clinics
• Group practices
• Managed care facilities
• Virtually all outpatient settings (i.e. institutions other than hospitals)

How Do I Become Certified as a CCS-P?

Becoming a CCS-P requires taking the CCS-P exam administered by AHIMA. This exam lasts four hours and consists of two parts. The first section consists of 60 multiple choice questions, 50 of which are counted towards your score. Part II of the CCS-P exam requires you to code 16 different medical records using procedural code sets (HCPCS Level II and CPT) and the diagnostic code set (ICD-9-CM). The 16 cases are broken down into medicine (3), surgery (6), emergency room (6) and one extra case from another section of medical coding.

The CCS-P exam costs $299 for AHIMA members and $399 for non-members. 388 individuals took the CCS-P exam in 2010 for the first time. Of these individuals, 52.1% passed and received their CCS-P credentials. In order to pass the CCS-P exam, you must achieve a score of at least 36 out of 50 on the multiple choice section and 222 out of 300 on the coding section. The CCS-P exam breaks down as follows:

24% – ICD-9-CM Diagnosis Coding

• Properly assigning diagnostic codes by consulting the AHA Coding Clinic.
• Referencing “Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office)” in order to assign ICD-9-CM codes.
• Applying the definitions, tables, instructional notations, formats and conventions found in ICD-9-CM to select the proper problems, conditions, diagnoses and other reasons for medical encounters.

24% – HCPCS Level II and CPT Coding

• Selecting supplies, services and procedures that require coding based on CPT instructional notes, formats and guidelines.
• Assigning CPT codes for various medical services and procedures, such as medicine, pathology and laboratory, radiology, surgery, anesthesia, Evaluation and Management and Category III.
• Applying modifiers to HCPCS Level II and CPT codes when necessary.
• Selecting supplies, drugs, procedures and services requiring coding based on HCPCS Level II instructional notes and guidelines.
• Assigning HCPCS Level II codes to supplies, drugs, procedures and services.

18% – Health Information Documentation

• Locating appropriate source documentation in patient health records for data collecting and coding.
• Interpreting patient health documentation and using an understanding of medical terminology, pharmacology, clinical disease processes, physiology and anatomy to correctly code procedures and diagnoses.
• Determining when it would be impossible to properly validate or assign codes without additional clinical documentation.
• Consulting with non-physician practitioners and physicians when additional documentation is required to clarify ambiguous or conflicting information.
• Interpreting health information documentation using clinical reference materials.
• Determining which components of documentation are irrelevant to or unnecessary for accurate coding.

10% – Data Quality and Analysis

• Validating the completeness and accuracy of coded data through documentation comparisons.
• Using generated reports to assess the quality and accuracy of billing and coding.
• Verifying the completeness and accuracy of claim data.
• Measuring trending and compliance by conducting medical billing and coding audits.
• Educating health care practitioners and staff regarding regulations, documentation rules and reimbursement methodologies as they pertain to medical coding.

10% – Compliance and Regulatory Issues

• Identifying and reporting compliance findings and concerns.
• Ensuring that the completeness and accuracy of patient medical records meet the standards of external regulations, organizational policies and industry-wide standards, including those pertaining to PA co-sign requirements, teaching physician rules and signatures.
• Developing coding policies that ensure compliance with coding guidelines and rules.
• Using both hardware and software technology to protect the validity and integrity of medical data.
• Recognizing and reporting privacy problems.
• Applying the AHIMA Standards of Ethical Coding and Code of Ethics.
• Releasing patient data to the proper authorities.
• Applying general procedures and policies to the disclosure of and access to personal health records.

8% – Reimbursement

• Processing claim appeals and denials.
• Evaluating payment and payer remittance reports, such as EOMB, EOB and RA, for denials and reimbursements.
• Using payer guidelines and documentation for identifying, posting and submitting charges for services.
• Linking diagnosis codes to their associated procedural codes for reporting and medical billing.
• Applying reimbursement methodologies such as Federal Register, CMS and OIG to reporting and billing.
• Applying unbundling and bundling guidelines, such as NCCI (National Correct Coding Initiative).
• Creating and maintaining charge tickets and encounter forms, as well as their electronic equivalents.

6% – Communication and Information Technologies

• Using common software programs including encoders, email, spreadsheets and word processors to complete basic daily work tasks.
• Using specialized computer systems to collect, store, analyze and report data and information.

Other Eligibility Requirements

In order to sit for the CCS-P exam, individuals must first obtain a high school diploma or an equivalent educational achievement such as a GED. AHIMA also recommends that students complete coursework in areas such as pharmacology, physiology, pathophysiology and anatomy. Though this is not required, it will improve your chances of passing the exam. AHIMA also strongly suggests that prospective CCS-Ps have three or more years of professional experience as a medical coder in various settings, such as physicians’ clinics, operating rooms, emergency rooms and hospitals. Your work experience should consist largely of using the laboratory, radiology, anesthesia, medicine, surgery and E/M (Evaluation and Management) chapters of the HCPCS Level II and CPT code sets.

CCA – Certified Coding Associate

CCAs are expert medical coders capable of working in both inpatient and outpatient healthcare settings. CCAs:

• Show a strong commitment to the field of medical coding.
• Are capable and knowledgeable medical coders, exhibiting the professional capability and competency sought after by employers.
• Are easily distinguishable from medical coders that do not have proper credentials by employers and professional organizations across the country.

Where do CCAs Work?

CCAs work in the following settings:

• Hospitals
• Physicians’ offices
• Mental health facilities
• Nursing homes
• Home health agencies
• Public health agencies
• Insurance companies

How Do I Become Certified as a CCA?

Taking the CCA examination administered by AHIMA allows you to obtain a CCA certification. The exam lasts for two hours and consists of 100 multiple choice questions, 90 of which actually count towards your score. The exam costs $199 for AHIMA members and $299 for non-members. 2,510 individuals took the CCA exam for the first time in 2010. Of these individuals, 60.5% passed. In order to pass the CCA exam, you must score at least 300 out of 400. The CCA exam was revised as of March 31, 2011, and it is outlined as follows:

32% – Classification Systems

• Sequencing codes according to various healthcare settings.
• Applying inpatient, outpatient and physician coding guidelines.
• Assigning inpatient, outpatient and physician codes.
• Interpreting healthcare data in order to assign codes.
• Incorporating the various terminologies and clinical vocabularies as they pertain to different health information systems.
• Viewing medical records in order to abstract the pertinent information for coding.
• Facilitating accurate code assignments by consulting reference materials.

23% – Reimbursement Methodologies

• Achieving optimal reimbursement by sequencing codes.
• Using payer specific guidelines to link CPT codes and diagnosis codes.
• Assigning the correct APCs (ambulatory payment classifications) and DRGs (diagnosis related groups).
• Evaluating National Correct Coding Initiative (NCCI) edits.
• Reconciling NCCI edits.
• Communicating with physicians to clarify medical documentation.
• Communicating with budgeting and financial departments.
• Using national coverage determinations (NCD) and local coverage determinations (LCD) to validate medical necessity.
• Submitting claim forms.
• Evaluating and responding to claim denials.
• Re-submitting denied claims to payer sources.

15% – Health Records and Data

• Retrieving medical record information.
• Assembling medical records in various healthcare settings.
• Quantitatively analyzing medical records for completeness.
• Qualitatively analyzing medical records for deficiencies.
• Performing data abstraction.
• Generating data analysis reports.
• Educating providers regarding health data standards.
• Using a master patient index to retrieve patient information.
• Requesting documentation specific to patients from sources such as physicians’ offices and ancillary departments.

14% – Compliance

• Preparing a healthcare organization for external compliance audits.
• Educating healthcare providers regarding coding compliance.
• Researching and implementing the most recent coding changes.
• Interpreting the latest coding changes to update charge and fee tickets.
• Querying physicians to clarify medical documentation.
• Coding ethically.
• Comparing supporting documentation and coded data to identify discrepancies.
• Ensuring that proper documentation supports codes assigned by electronic systems and/or providers.

8% – Confidentiality and Privacy

• Maintaining patient confidentiality.
• Informing healthcare staff of confidentiality and privacy issues.
• Utilizing pass codes.
• Ensuring a secure professional environment.
• Recognizing and reporting potential privacy violations and issues.
• Accessing no more than the minimal information and required documentation.
• Releasing patient healthcare data only to proper authorities.
• Using secure sites to transfer electronic health documents.
• Using data encryption to protect electronic health documents.
• Retaining and destroying confidential records as deemed appropriate by organizational policies and established industry guidelines.

8% – Information Technology

• Navigating EHRs (electronic health records)
• Utilizing health information management and practice management systems.
• Using grouping and encoding software.
• Using computer assisted coding software, or CAC, to automatically assign medical codes based on text.
• Validating the accuracy of codes automatically assigned by CAC software.

Other Eligibility Requirements

In order to be eligible for the CCA exam, you must have at least a high school diploma or GED. AHIMA also strongly recommends that you possess at least six months of professional experience applying CPT and ICD-9-CM coding guidelines and conventions in a healthcare organization. Alternatively, you can complete a coding certificate program approved by AHIMA or another professional organization devoted to the field of medical billing and coding.

CHPS – Certified in Healthcare Privacy and Security

CHPSs specialize in the streamlining of patient medical information in order to improve patient safety, privacy and security and reduce care delivery costs. CHPSs:

• Design, implement and administer security and privacy protection programs in a wide variety of healthcare organizations.
• Are committed to the advancement of security and privacy management practices, demonstrated through professional development and continuing education.
• Are excellent candidates for professional advancement due to their decision to specialize in the security and privacy aspects of health information management.

Where do CHPSs Work?

CHPSs can work in a range of outpatient and inpatient healthcare settings, including:

• Physicians’ offices
• Hospitals
• Multispecialty clinics
• Mental health facilities
• Ambulatory care facilities
• Insurance companies
• Long-term care facilities
• Managed care organizations
• Insurance companies
• Software vendors
• Educational facilities
• Governmental agencies
• Pharmaceutical companies
• Consulting services

How Do I Become Certified as a CHPS?

You can become certified as a CHPS by taking the CHPS exam administered by AHIMA. This exam lasts for four hours and consists of 165 multiple choice questions, 135 of which count towards your actual score. The CHPS exam costs $259 for AHIMA members and $329 for non-members. A total of 52 individuals took the CHPS exam in 2010. Of these individuals, only 40.4% passed the exam after a single try and received their credentials. The CHPS exam has the lowest pass rate of any exam administered by AHIMA. In order to pass this exam, you must achieve a score of at least 300 out of 400. The CHPS exam is outlined as follows:

23% – Investigation, Compliance and Enforcement

• Establishing complaint and incident investigation methods and resolution processes for security and privacy infringements.
• Monitoring staff access to PHI.
• Complying with accrediting and regulatory bodies as well as state and federal governments by enforcing security and privacy guidelines, procedures and policies.
• Creating performance reports and measures in order to report to appropriate organizational bodies and gauge and improve organizational performance.
• Ensuring that the ways in which an organization responds to external investigations and inquiries are in line with organizational procedures and policies.
• Updating organizational procedures, policies and practices and training staff members to ensure compliance with evolving federal and state laws pertaining to security and privacy.

22% – External Environmental Assessment / Regulatory, Legal and Ethical Issues

• Guiding your organization with regards to the standards, regulations, and security and privacy laws imposed by accreditation agencies in order to interpret and apply their standards.
• Complying with the security and privacy standards imposed by accrediting agencies and federal and state governments as they pertain to retention, production and documentation.
• Developing various incident response plans and identifying members of administration, IT, public relations, law enforcement, physical security and risk management, as well as legal and human resources departments that should respond to security and privacy incidents.

22% – Program Management and Administration

• Overseeing programs by administering appropriate information security and privacy organizational infrastructures.
• Creating, communicating and documenting security and information privacy policies, authorizations, consents, procedures and notices of privacy practices.
• Identifying potential business relationships and contracts to secure appropriate security and privacy agreements.
• Managing business contracts throughout their existence.
• Preventing tampering, theft and the unauthorized access of medical information by monitoring and evaluating organizational security plans.
• Informing a workforce of security and privacy issues by developing, evaluating, documenting and delivering awareness and training programs.
• Consulting with the appropriate officials in an organization in order to verify that any data released for research purposes complies with privacy and security regulations as well as organizational procedures and policies.
• Evaluating, revising and communicating changes to organizational privacy and security practices, procedures and policies.
• Evaluating and communicating the ramifications and risks of security and privacy breaches, including those committed by external associates.
• Preventing, detecting and mitigating security and privacy breachers by establishing preventative programs.
• Applying various methods of de-identification.
• Verifying the authorization and permission levels of those who request protected information, such as through search warrants, court orders and subpoenas.
• Defining record sets designated by HIPAA in order to allow an organization to correctly respond to information release requests.
• Identifying which record and information sets require special privacy protection.
• Establishing minimum necessary procedures.
• Verifying the access rights and identities of users and recipients of health information by reviewing and approving protocols.

18% – Physical and Technical Safeguards and Information Technology

• Facilitating risk assessment and protecting information assets by developing and verifying plans to maintain inventories of hardware, software and data.
• Planning contingency plans for disaster recovery and emergencies and establishing business continuity plans to accommodate planned downtime.
• Evaluating, selecting and implementing information security and privacy solutions.
• Evaluating criticalities of and risks to information systems containing patient health information through systematic processes.
• Assessing, implementing and managing media control techniques to govern the removal, receipt, re-use and disposal of devices and media that contain sensitive information in order to protect the security, privacy and confidentiality of information.
• Monitoring and assessing physical security mechanisms in order to prevent information, equipment and facilities from being accessed by unauthorized personnel.
• Reducing incidental disclosures by establishing reasonable safeguards.
• Developing and managing organization-wide information security plans.
• Identifying vulnerabilities and threats by developing organizational risk assessment plans.
• Ensuring that organizations comply with security policies.
• Ensuring the adequacy of preventive countermeasures, intrusion detection, configuration management and other technical safeguards.
• Complying with security requirements and protecting information through internal rules, policies and procedures.
• Protecting information transmitted to and received from external users, such as PHRs, RHIOs and HIEs, by applying appropriate technologies.
• Employing various data backup plans.
• Ensuring the integrity, confidentiality and availability of communications across networks (including PKI, VPNs, secure sockets, Internet and wireless) by developing guidelines, controls and procedures.
• Identifying abnormal system conditions such as invalid log-in attempts, denials of services and intrusion detections by using event triggering.
• Managing verification and control policies to monitor access privileges and authorizations, such as emergency access.
• Managing authentication mechanisms.
• Using risk assessment techniques to measure the encryption strength of PHI, or protected health information.

15% – Patient/Customer/Client Services

• Creating, maintaining and distributing the Notice of Privacy Practices of an organization.
• Informing patients of their rights in terms of the disclosure and use of protected health information.
• Creating and maintaining systems in order to receive and document requests pertaining to complaints, restrictions, alternate methods of communication, accounting of disclosures, access to protected health information, and amendments.
• Creating and implementing organization-specific communication tools to make clients aware of the organization’s dedication to client rights, services, security and privacy.
• Maintaining a system of breach notification by maintaining appropriate documentation, developing clear procedures and policies, using risk assessment tools, educating staff regarding reporting requirements and notifying the appropriate agencies and individuals in a timely fashion.

Other Eligibility Requirements

In order to be eligible to sit for the CHPS exam, you must have a bachelor’s degree and four years of professional experience in healthcare management. Alternatively, you sit for the exam if you have a master’s or PhD along with two years of professional experience in the same field. Finally, you’ll be eligible if you are already certified by AHIMA as an RHIA or an RHIT and you possess a bachelor’s degree as well as at least two years of professional work experience in managing healthcare. You can verify your work experience by submitting a professional resume that details your experience managing projects and/or people in a healthcare setting.

CHDA – Certified Health Data Analyst

CHDAs analyze healthcare data in order to meet the evolving needs of the health information management industry, which is currently transitioning towards an entirely electronic system. CHDAs:

• Are recognized nationwide for their mastery of health data analysis.
• Acquire, interpret, analyze, manage and translate health data into timely, consistent and accurate information.
• Use this data to balance the daily operations of an organization with the organization’s ultimate goals and strategic visions.
• Frequently communicate with medical billers and coders inside and outside of their own organizations.
• Possess excellent knowledge of organizational principles.

Where do CHDAs Work?

As with CHPSs, CHDAs work in a wide variety of inpatient and outpatient settings. These include:

• Pharmaceutical companies
• Governmental agencies
• Physician offices
• Educational facilities
• Software vendors
• Long-term care facilities
• Insurance companies
• Hospitals
• Managed care organizations
• Ambulatory care facilities
• Insurance companies
• Multispecialty clinics
• Consulting services
• Mental health facilities

How Do I Become Certified as a CHDA?

A prospective CHDA must take and pass the CHDA examination administered by AHIMA. This exam lasts a total of 3 hours, 45 minutes and consists of 154 multiple choice questions. The exam costs $259 for AHIMA members and $329 for non-members. A total of 24 individuals took the CHDA exam in 2010 for the first time. Of these individuals, 58.3% passed and received their credentials. In order to pass the CHDA exam, you must receive a score of at least 300 out of 400. The CHDA exam is outlined as follows:

32% – Data Management

Assisting in developing and maintaining a data architecture and model in order to support an organization’s needs for a database design foundation.

Requires an understanding of…

• SQL and XML database languages.
• EHR (Electronic Health Record) systems.
• Relational database structures including primary key and secondary key.
• Various basic architecture platforms including SQL server and Oracle.
• Physical, logical and conceptual data models.
• The relationship between an organization’s strategic priorities, goals and hard medical data.

Creating a reference tool, such as a data dictionary, by establishing uniform definitions for the data captured by source systems.

Requires an understanding of…

• Industry data set requirements for LOINC, SNOMED, UN-04, CPT and ICD-9-CM as well as reference terminology and classification systems.
• Applicable data standards such as HL7, CDISC and ASTM.

Ensuring the reliability and accuracy of data by formulating validation methods and strategies, including audits, reports and system edits.

Requires an understanding of…

• Best auditing practices pertaining to audit logs, system audit trails and auditing guidelines.
• Regulatory requirements and industry standards.
• Systems testing as it relates to user acceptance, interface, load and integration.

Developing specifications to produce accurate, correctly reported data by using field mapping and data tables to evaluate current data structures within an organization.

Requires an understanding of…

• Classification systems data from LOINC, SNOMED, CPT and ICD-9-CM.
• Standardized administrative healthcare data found in CMS form 1500 and UB-04.

Providing data for reporting and analysis by integrating data as it arrives from both external and internal sources.

Requires an understanding of…

• Basic software programs including databases, presentation tools, spreadsheets and word processors.
• Primary key and secondary key relational database structures.
• Terminology systems, reference classification systems and industry data set requirements contained in LOINC, SNOMED, UB-04, CPT and ICD-9-CM.
• Source systems including financial, radiology, pharmacy and HIS systems.

Ensuring accurate, high quality data by updating and maintaining tables used in an organization’s information systems.

Requires an understanding of…

• Industry standard mapping guidelines between various classification systems.

Periodic updates of data in source systems.

• Data table structuring.
• The history of various classification systems, such as retired codes and how they may still be used with new descriptors.
• Industry data set requirements pertaining to revenue codes, UB-04, CPT and ICD-9-CM.
• Reference terminology and reference classification systems.
• Pharmacy, radiology, HIS, financial and other source systems.
• Applicable data standards such as HL7, CDISC and ASTM.

37% – Data Analytics

Generating findings for interpretation by using the appropriate testing methods to analyze health data.

Requires an understanding of…

• Various data mining techniques and their appropriate uses.
• SPSS and SAS procedures.
• Database query syntax including SQL.
• The basic principles of operational, financial and clinical data.

Creating recommendations for operational, financial and clinical processes by interpreting analytical findings.

Requires an understanding of…

• Industry-standard terms for operational, financial and clinical data.
• Various classification systems.
• Healthcare reimbursement methodologies.
• Medical terminology.
• Various business processes, such as payer and regulatory guidelines, system limitations and workflow.
• Risk adjustment techniques.
• Outcome measures, processes and quality standards.

Using quantitative and qualitative data analysis to validate results and confirm findings.

Requires an understanding of…

• Source data field attributes and content.
• Healthcare operations used to improve financial and clinical outcomes.
• Quantitative and qualitative analysis techniques.

31% – Data Reporting

Collecting and interpreting data to design criteria and metrics that meet an end user’s needs.

Requires an understanding of…

• Outcome measures and quality standards.
• The basic principles of operational, clinical and financial data.
• Classification systems, nomenclature and clinical vocabularies including NDC, SNOMED-CT, LOINC, HCPC, CPT and ICD.
• Standardized healthcare data sets.

Completing data requests by using external and internal data sources to generate ad-hoc and routine reports.

Requires an understanding of…

• SPSS and SAS procedures.
• Database programs including Microsoft Access and SQL Server.
• Basic database query syntax.

Determining the needs of a given target audience in order to present information data in a clear, concise, easily understood format.

Requires an understanding of…

• Various modes of presentation, such as AV, teleconferencing and web conferencing, and how to choose the appropriate one.
• Various Microsoft Office applications including Access, PowerPoint, Excel and Word.
• The stakeholders within a healthcare delivery system.

Improving business outcomes and processes by offering recommendations based on the results of analyzed data.

Requires an understanding of…

• The stakeholders within a healthcare delivery system.
• The healthcare industry in general.

Other Eligibility Requirements

In order to sit for the CHDA exam, you must possess a bachelor’s degree in addition to five years of professional experience specific to healthcare data. Alternatively, you can take the exam if you’re already certified as an RHIA and you possess at least one year of professional healthcare data experience. You can verify your work experience by submitting a resume that details your experiences with healthcare data reporting, analysis and management.