Preparing for the CCS and CCS-P Exams

Vol. 14 •Issue 3 • Page 12
CCS Prep!

Preparing for the CCS and CCS-P Exams

This column will continue to serve as a resource for those who are preparing to take the certified coding specialist (CCS) and CCS-P (physician-based) examina-tions offered by the American Health Information Management Association (AHIMA). The dates for the 2004 examinations are June 12th and September 18th.

The AHIMA Web site ( /certification/) has extensive information to review and help you prepare for the exam as well as application forms. If you are not yet a member of AHIMA, it is recommended that you join. If you are a member, the Communities of Practice (COP) ( offer up-to-date coding news, links to helpful resources and, most importantly, a vehicle to interact with others preparing to take the examination. You should consider joining the various coding, student and coding education COPs.

In previous years, links and information that could be used to prepare for either exam was included. Instead of dedicating a column with the same information we suggest that you go to ADVANCE’s Web site and review the 2003 column titled “Steps to Prepare for the CCS and CCS-P Exam.” This information can be found at The column provides general preparation tips and suggestions, as well as recommended study material. Keep in mind that some of the material in the 2003 column has been updated for 2004.

This column will review changes to the ICD-9-CM Official Guidelines for Coding and Reporting published by the cooperating parties for ICD-9-CM, which include the American Hospital Association (AHA), AHIMA, Centers for Medicare and Medi-caid Services (CMS) and the National Center for Health Statistics (NCHS). The changes to the guidelines are effective Oct. 1, 2003 and can be accessed at The new guidelines related to SIRS will be reviewed in detail.

As indicated in the 4th Quarter 2003 Coding Clinic, there have been many questions on the proper coding of infections since the creation of the series of codes for systemic inflammatory response syndrome (SIRS), effective Oct. 1, 2002, and the inclusion of the term sepsis under code 995.91, SIRS due to infectious process without organ dysfunction, effective with the Oct. 1, 2003 update. As a result, the Septicemia and Septic Shock guidelines in Section I of the Official Guidelines have been completely revised. This section is now called Sep-ticemia, Systemic Inflammatory Response Syndrome (SIRS), Sepsis, Severe Sepsis and Septic Shock, and provides clear instructions on how to properly code and sequence these conditions. The following coding guideline on reporting sepsis and septic shock that had been in effect for a number of years has been deleted.

“When the diagnosis of septicemia with shock or the diagnosis of general sepsis with septic shock is documented, code and list the septicemia first and report the septic shock code as a secondary condition. The septicemia code assignment should identify the type of bacteria if it is known.”

The new guidelines for Septicemia, Systemic Inflammatory Response Syn-drome (SIRS), Sepsis, Severe Sepsis and Septic Shock are outlined here.

1. In most cases, it will be a code from category 038, Septicemia that will be used in conjunction with a code from subcategory 995.9, Systemic inflammatory response syndrome. If the documentation in the record states streptococcal sepsis, codes 038.0 and code 995.91 should be used, in that sequence. If the documentation states streptococcal septicemia, only code 038.0 should be assigned, however, the physician should be queried whether the patient has sepsis, an infection with SIRS. Either the term sepsis or SIRS must be documented to assign a code from subcategory 995.9.

To follow the above guideline, the definition of septicemia, SIRS and sepsis must be understood. Septicemia has been defined as systemic disease associated with the presence of pathological microorganisms or toxins in the blood, which can include bacteria, viruses, fungi or other organisms. SIRS is the systemic response to infection or trauma, with symptoms including fever, tachycardia, tachypnea and leukocytosis. Sepsis is defined as SIRS due to infection. This definition of sepsis identified in the 4th Quarter 2003 Coding Clinic supersedes all previously published Coding Clinic advice where sepsis was equated with septicemia. Severe sepsis is defined as sepsis with associated organ dysfunction.

2. If the terms sepsis, severe sepsis or SIRS are used with an underlying infection other than septicemia, such as pneumonia, cellulitis or a nonspecified urinary tract infection, code 038.9 should be assigned first, then code 995.91, followed by the code for the initial infection. This is because the use of the terms sepsis or SIRS indicates that the patient’s infection has advanced to the point of a systemic infection. In these instances the systemic infection should be sequenced before the localized infection. The instructional note under subcategory 995.9 instructs coders to assign the underlying condition first. It’s important to note that the term urosepsis is a nonspecific term. If that is the only term documented then only code 599.0 should be assigned, in addition to the code for the causal organism if known.

3. For patients with severe sepsis, the code for the systemic infection (038.x) or trauma should be sequenced first, followed by either code 995.92, Systemic inflammatory response syndrome due to infectious process with organ dysfunction, or code 995.94, Systemic inflammatory response syndrome due to noninfectious process with organ dysfunction. Codes for the specific organ dysfunctions should also be assigned.

4. If septic shock is documented, it is necessary to code first the initiating systemic infection or trauma, then either code 995.92 or 995.94, followed by code 785.52, Septic shock. Septic shock is sepsis with hypotension, a failure of the cardiovascular system. Therefore, septic shock meets the definition for severe sepsis. These guidelines supersede advice previously published in Coding Clinic First Quarter 1988, pp. 1-3, and Second Quarter 2000, pp 3-4.

The terms endo-toxic shock and gram negative shock are synonymous with septic shock. If the term endo-toxic shock and gram negative shock are documented in a medical record, the code for septic shock should be assigned. These terms are still listed as inclusion terms under code 785.59, Other shock without mention of trauma. This error in the tabular list will be corrected with the Oct. 1, 2004 addenda.

5. Sepsis and septic shock associated with abortion, ectopic pregnancy and molar pregnancy are classified to category codes in Chapter 11 (630-639).

6. Negative or inconclusive blood cultures do not preclude a diagnosis of septicemia or sepsis in patients with clinical evidence of the condition, however, the physician should be queried.

The other significant changes to the Official Guidelines are related to long-term care hospitals (LTCH). Section II (Selection of Principal Diagnosis) and Section III (Reporting Additional Diagnoses) have been clarified to indicate that the uniform hospital discharge data set (UHDDS) definitions also apply to LTCHs. Because the concept of principal diagnosis may be new to LTCHs, hospitals must educate their physicians regarding the importance of clearly documenting the reasons for admission to LTCH just as acute care hospitals had to train their physicians with the advent of DRGs. Without this collaboration, LTCH coders may find it difficult, if not impossible, to select the principal diagnosis. Depending on the medical record documentation, LTCHs may assign codes for acute unresolved conditions or codes for late effect or rehabilitation.

The CCS and CCS-P exams do include questions regarding these guidelines, and many of the coding scenarios do utilize these guidelines. Therefore, it is very important to review and know them before you take the exam. Previous CCS-Prep columns discussing both the Official Inpatient and Outpatient Coding Guidelines in detail can be accessed at

The columns on tips and resource suggestions and the Official Inpatient and Outpatient Coding Guidelines will help you get started in your preparation to take the CCS or CCS-P exam. In upcoming issues of CCS Prep! we will continue to address specific topics. Should you have a topic you would like included, send an e-mail to ADVANCE at [email protected].

When you are ready, take the following quiz to test your knowledge.

1. A patient was admitted to an LTCH for continued treatment of chronic severe in-tractable pain secondary to diabetic peripheral polyneuropathy. The patient had a history of stroke in the past with residual left hemiparesis, nondominant side. Which of the following would be the appropriate code selection?

a. 250.60, 357.2, V12.59

b. 250.60, 438.22

c. 357.2, 438.22

d. 250.60, 357.2, 438.22

2. The patient was discharged with a diagnosis of sepsis due to pneumonia. Which of the following would be the appropriate code selection?

a. 038.9, 995.91, 486

b. 99591, 038.9, 486

c. 486, 995.91, 0389

3. How would you code the diagnosis that is stated simply as “sepsis?”

a. 038.9

b. 995.91

c. 038.9, 995.91

d. 995.91, 038.9

4. The patient was admitted to the LTCH for general rehabilitation as well as postoperative aftercare. She received physical and occupational therapy. The patient has a his- tory of pathologic compression fracture and is status post corpectomy with spinal fusion. Which of the following would be the appropriate code selection?

a. V54.27, V57.89

b. V54.27

c. V57.89, V54.27

d. V57.89

This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (, which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Coding Clinic is published quarterly by the American Hospital Association.

CPT is a registered trademark of the American Medical Association.


1. d: Assign code 250.60, Diabetes with neurological manifestations, as the principal diagnosis. Codes 357.2, Polyneuropathy in diabetes, and 438.22, Hemiplegia affecting nondominant side, should be assigned as additional diagnoses. Chronic pain syndrome is coded to the underlying condition. In this case, the chronic pain was due to the diabetic peripheral polyneuropathy.

2. a: The coding guideline states: If the terms sepsis, severe sepsis or SIRS are used with an underlying infection other than septicemia, such as pneumonia, cellulitis or a nonspecified UTI, code 038.9 should be assigned first, then code 995.9X, followed by the code for the initial infec- tion. In this instance the underlying infection is pneumonia.

3. c: The code first note at subcategory 995.9 provides instruction that the underlying cause of the SIRS (infection or trauma) should be coded first. In the absence of a specified underlying condition, the de-fault first code assigned should be 038.9. If only the term sepsis is documented, codes 038.9 and 995.91 would be assigned, in that sequence.

4. c: Assign code V57.89, Other specified rehabilitation procedure, as the principal diagnosis and code V54.27, Aftercare for healing pathologic fracture of vertebrae as an additional diagnosis.