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What Is the CCS Certification Exam?
The CCS certification exam is a standardized assessment designed to measure a candidate's knowledge, competencies, and practical understanding within a defined professional field. It serves as the primary requirement for earning the Certified Coding Specialist (CCS), a credential that represents a recognized level of proficiency in its respective industry. Depending on the field, this may involve theoretical knowledge, applied problem-solving, regulatory understanding, or hands-on procedural competence.
The exam is typically developed and maintained by an accrediting body or professional organization that sets the standards for the Certified Coding Specialist (CCS). This ensures that anyone who earns the credential has met a consistent benchmark, regardless of where they studied or gained their experience. For many professionals, the CCS Certification Exam represents a formal checkpoint in their career, one that confirms readiness to take on greater responsibility within their chosen field.
Why the Certified Coding Specialist (CCS) Certification Matters?
Certifications like the Certified Coding Specialist (CCS) exist because industries need a reliable way to verify competence beyond a resume or a job title. Earning this credential signals to employers, clients, and colleagues that a professional has invested time in building a structured foundation of knowledge and has been evaluated against an established standard.
Beyond individual recognition, the Certified Coding Specialist (CCS) certification often supports broader professional development. It can influence hiring decisions, contribute to internal advancement, or serve as a prerequisite for more specialized roles within the field. In many industries, certifications also help standardize expectations across organizations, making it easier for professionals to move between employers or sectors while carrying a credential that is widely understood and respected.
Who Should Take the CCS Exam?
The CCS exam is generally relevant to individuals who are either entering a field or looking to formalize skills they have already developed through experience. This can include early-career professionals seeking a credential to support their first steps into the industry, as well as experienced practitioners who want official recognition of knowledge gained on the job.
Students preparing to enter the workforce may also pursue the CCS exam as a way to strengthen their qualifications before graduating or applying for their first roles. In some fields, employers actively encourage or require staff to pursue this certification as part of ongoing professional development, particularly in industries where standards, safety, or compliance play a significant role in daily responsibilities.
Knowledge and Skills Evaluated in the Certified Coding Specialist (CCS) Exam
The Certified Coding Specialist (CCS) Exam is built to evaluate both foundational knowledge and the practical judgment needed to apply that knowledge in real situations. Candidates are generally expected to understand core principles and terminology relevant to their field, along with the reasoning behind established procedures, standards, or best practices.
Depending on the industry, this may include understanding regulatory requirements, following established protocols, applying analytical or technical methods, or exercising sound judgment in situations that require careful decision-making. Rather than testing isolated facts in a vacuum, the Certified Coding Specialist (CCS) Exam tends to reward candidates who can connect concepts to realistic scenarios, reflecting the kind of thinking expected in day-to-day professional practice.
CCS Exam Preparation Resources
Preparing for the CCS certification exam becomes more effective when using high-quality and up-to-date study materials. MyCertsHub provides resources designed to help candidates build knowledge, practice consistently, and become familiar with the actual exam format.
Effective preparation for the CCS certification exam usually begins with a clear understanding of the exam's objectives and structure. Reviewing official guidelines or documentation published by the certifying body provides the most accurate picture of what will be covered and how heavily different areas are weighted.
From there, many candidates benefit from building a structured study plan that breaks preparation into manageable sections over a set period of time. A well-organized CCS Study Guide can help sequence this material logically, especially for those approaching a topic for the first time. Consistent review, paired with realistic practice, tends to produce better retention than concentrated last-minute studying.
Practical experience, where applicable to the field, also plays an important role in preparation. Working through CCS Practice Questions and a CCS practice test can help candidates identify gaps in their understanding and become familiar with the format and pacing of the actual exam. In fields where hands-on skill is assessed, supplementing study with real-world practice or supervised experience often makes the difference between recognizing correct information and genuinely understanding it.
Benefits of Earning the Certified Coding Specialist (CCS) Certification
Successfully earning the Certified Coding Specialist (CCS) certification offers benefits that extend well beyond passing a single exam. It provides documented proof of competence that can be referenced on a resume, professional profile, or internal performance review, offering a clear, third-party validation of skill and knowledge.
The credential can also strengthen professional credibility when working with clients, patients, stakeholders, or colleagues who may not be positioned to evaluate technical or specialized knowledge directly. Over time, this recognition often contributes to expanded career opportunities, whether through new responsibilities, higher-level roles, or eligibility for additional certifications that build on this foundational credential.
Prepare for the CCS Exam with MyCertsHub
Preparing for the CCS exam is a process that benefits from organized, consistent effort rather than rushed, last-minute review. MyCertsHub is designed to support that process by offering study resources, practice materials, and educational content that help candidates understand what the Certified Coding Specialist (CCS) Exam covers and how to approach their preparation thoughtfully.
Whether someone is just beginning to explore the Certified Coding Specialist (CCS) or is in the final stages of reviewing material before their exam date, MyCertsHub aims to serve as a dependable resource throughout that journey. Every candidate's path to certification looks a little different, and the goal remains the same: to provide clear, genuinely useful information that supports real understanding of the subject matter.
FAQ
AHIMA CCS Frequently Asked Questions
The AHIMA CCS (Certified Coding Specialist) credential is widely recognized for validating advanced coding knowledge used in hospitals and healthcare organizations. It demonstrates that a professional can accurately assign medical codes while following current coding guidelines and documentation standards.
Earning the certification can help strengthen your professional credibility and show employers that you are committed to maintaining high coding accuracy and compliance.
While there may not always be a strict experience requirement, candidates with practical coding experience often feel more comfortable with the exam. Familiarity with medical terminology, anatomy, reimbursement systems, and coding guidelines provides a strong foundation.
Those who are newer to medical coding can still prepare successfully by following a structured study plan, reviewing official resources, and practicing consistently before scheduling the exam.
Practice tests help candidates become familiar with the structure and pacing of the AHIMA CCS exam while identifying topics that require additional review. They also improve confidence by encouraging critical thinking under exam-like conditions.
Many candidates include realistic AHIMA CCS practice questions in their study routine to monitor progress and reinforce important coding concepts before exam day.
A practical study schedule should divide the exam objectives into manageable sections and include regular review sessions. Consistency is usually more effective than studying for long hours only occasionally.
Many successful candidates combine textbook study, coding exercises, official references, and AHIMA CCS practice tests to build knowledge gradually while tracking their improvement over time.
The AHIMA CCS credential is often valued by employers seeking skilled coding professionals for hospitals, healthcare systems, insurance organizations, and related medical settings. It demonstrates advanced coding competency and a commitment to professional development.
Although hiring decisions depend on several factors, combining certification with practical experience and continuous learning may improve career opportunities within the healthcare coding field.
The final week should focus on reinforcing concepts rather than learning entirely new material. Reviewing coding guidelines, revisiting challenging topics, and completing timed practice questions can help strengthen your readiness.
Avoid cramming at the last minute. A balanced approach that includes adequate rest and organized review often leads to better concentration during the exam.
One of the most effective ways to evaluate your preparation is by taking realistic practice exams and reviewing every incorrect answer. Understanding why an answer is wrong is just as valuable as knowing why another is correct.
Study resources available through MyCertsHub can help candidates assess their knowledge with updated practice materials while identifying areas that deserve additional attention before the exam.
Accurate medical coding supports proper reimbursement, reliable healthcare records, regulatory compliance, and meaningful clinical reporting. The AHIMA CCS exam reflects these real-world responsibilities by testing both coding knowledge and sound decision-making.
Developing strong analytical skills alongside coding accuracy can help candidates perform more confidently both during the certification exam and in professional healthcare environments.
Many candidates prefer using a combination of official learning resources and additional practice materials during their preparation. MyCertsHub offers AHIMA CCS practice questions and mock tests designed to help learners evaluate their understanding and become familiar with exam-style questions.
Using practice exams as part of a broader study strategy can improve confidence, highlight weak areas, and support a more organized approach to preparing for the AHIMA CCS certification.
AHIMA CCS Sample Question Answers
Question # 1
After performing cystourethroscopy and ureteroscopy, a surgeon uses lithotripsy to destroy a left renal
calculus. Select the correct code.
A: 50590-22 B: 52320 C: 52353 D: 50592-22
Answer: C Explanation: Looking up Lithotripsy, Kidney in the CPT Index identifies a set of four codes. Code 52353 is the only one
of those four that also includes cystourethroscopy and ureteroscopy. Code 50590 pertains to extracorporeal
shock wave lithotripsy. The use of modifier -22 is not indicated here nor with code 50592, which pertains to
percutaneous radiofrequency ablation of a renal tumor. Code 52320 pertains to cystourethroscopy with
removal of ureteral calculus.
Question # 2
Which one of these measures/practices is HITECH Act compliant?
A: Using an unencrypted email account to send lab results if the patient signs a privacy waiver B: Instructing patients to forward pictures of their ailments via personal email C: Giving all employees access to the secure patient portal D: Using secure portals for responding to patients' health-related questions
Answer: D Explanation: The HITECH Act requires the privacy of patients' health information to be maintained when transmitting
data electronically, including when using email. Patients should be informed that communicating via email
may carry privacy risks, but they should not be asked to waive their privacy rights. Unencrypted email is not
a secure method of communication. A business email account with a business associate agreement in
place is a more secure way to transmit sensitive health information if email is the patient's chosen means of
communication. Secure portals are a good option for patient communication, but access should be limited
based on employees' roles.
Question # 3
A patient is admitted from the emergency department (ED) with a documented diagnosis of alcohol-induced
acute pancreatitis. Upon discharge two days later, his attending physician documents a diagnosis of
idiopathic acute pancreatitis. What is the next step?
A: Code as idiopathic acute pancreatitis because his blood alcohol level likely returned to normal. B: Code as alcohol-induced acute pancreatitis because that is the principal diagnosis recorded. C: Query the provider because idiopathic implies an unknown cause, but alcoholic indicates a known cause. D: Document both because pancreatitis can occur at any time from any cause.
Answer: C Explanation: When there is obviously conflicting documentation in the medical record, it is not the coder's responsibility
to assume or explain away the reason for the conflict. Clarification should be requested from the provider,
as it should in this case in which the cause of the disease is included in the code, but conflicting information on causation is documented.
Question # 4
A patient with a known gastric ulcer and no prior gastrointestinal bleeding is admitted for treatment of a hip
fracture. She later develops hematemesis, and a bleeding gastric ulcer is diagnosed. Which one of the following is true of the POA indicator for bleeding gastric ulcer?
A: Since this was a preexisting condition, Y is the correct choice. B: N is correct because neither one of the components of the code was present on admission. C: W is correct because we cannot tell when the bleeding started. D: No POA indicator is necessary because the bleeding started after admission.
Answer: B Explanation: ICD-10-CM guidelines (Appendix 1) instruct us that when a code contains multiple clinical concepts, they
all must be present on admission in order to assign a POA indicator of Y. If one or more of those clinical
concepts are not present on admission, the POA indicator is N. In this case, the code includes gastric ulcer
and bleeding, one of which was not present on admission, so N is the correct indicator. Indicator W is only
assigned when the provider documents that it cannot be clinically determined whether the condition was
present on admission. Because one of the clinical concepts was present on admission, a POA indicator is
necessary.
Question # 5
An operative note with "Left minithoracotomy" in the heading proceeds to what seems to be consistent with
video-assisted thoracoscopic surgery. How should the coder proceed?
A: Code the procedure listed in the heading because the documentation is clear. B: Code video-assisted thoracoscopic surgery because the procedure description is more important than the heading. C: Clarify with the surgeon so that the appropriate code can be selected. D: Check the preoperative note, and code the intended procedure.
Answer: C Explanation: A procedure should never be coded only from the heading of the report. If the description appears not to
match the heading. the coder must request clarification from the surgeon. Preoperative notes are not
definitive because various factors can cause a change in the planned procedure.
Question # 6
In what field does a coder NOT need basic knowledge in order to accurately abstract data from medical
records?
A: Medical terminology' B: Anatomy and physiology C: Biochemistry D: Pharmacoloy
Answer: C Explanation: Effective data abstraction requires basic knowledge of medical terminology' and anatomy/physiology. Some
knowledge of pharmacology would also be an asset. Biochemistry is not required for medical data
abstraction.
Question # 7
Which responses to a payers request for additional documentation is most likely to result in an insufficient
documentation error?
A: Ensuring that physicians' notes have a signature or signature attestation B: Including any relevant procedure notes in the submission C: Submitting abnormal imaging results to support medical necessity D: Resubmitting the original records since they might not have been reviewed
Answer: D Explanation: A request for additional information indicates that previously submitted records were deficient, so
resubmitting the same records is likely to result in an insuffcient documentation error. Instead, the
previously submitted documents should be rechecked to ensure that they are signed, that they support
medical necessity, and that no relevant reports were missed on the first submission.
Question # 8
Which one of the following is true of autonomous coding?
A: It has already made coding fully automatic, without the need for human intervention. B: It uses artificial intelligence, machine learning, and natural language processing. C: It eliminates the need for auditors by using bot programs to automate rules-based processes. D: It only became fully developed in 2015 when ICD-IO was implemented.
Answer: B
Explanation:
According to a 2022 white paper by AGS Health, autonomous coding uses artificial intelligence, machine
learning, and natural language processing. This emerging technology is still being developed, with the goal
of accelerating coding and improving accuracy to ultimately move coders into the role of auditors. Bot
programs would support auditors by performing routine processes, freeing auditors to focus on more
complex processes that require human input. The switch from ICD-9 to ICD-10 accelerated the
development of computer-assisted coding. but fully autonomous coding has still not been achieved
Question # 9
Which one of the following is true about the function of encoding software?
A: It increases productivity by eliminating the need for coding professionals. B: It automates the entire coding process so that formal training in coding becomes unnecessary. C: It facilitates code selection by improving speed and accuracy when a search term is entered. D: It uses artificial intelligence to transcribe patient encounters.
Answer: C Explanation: Encoding software facilitates code selection by speeding up the search process when coders enter a term
from the medical record. Encoders also improve accuracy and boost productivity, but they do not eliminate
the need for coders or for formal training in coding. Encoders are tools that make coding more efficient but
relying solely on them may lead to coding errors. Encoders do not transcribe encounters, but speech
recognition software may be used for this purpose.
Question # 10
A hospitalized patient has a recorded urine output of 0.4 mL/kg/h over the first six hours of her stay. The
only documented diagnosis is acute pyelonephritis. Which one of the following would be included in a
compliant query?
A: Based on the clinical indicators, do you agree that the patient also hasacute kidney injury? B: Based on the clinical indicators, what is the cause of the patient's acute kidney injury? C: Can you provide a diagnosis that represents the clinical indicators listed? D: Can you confirm that the decreased urine output is due to acute pyelonephritis?
Answer: C Explanation:
A compliant query will not diagnoses, and since the patient does not have a documented diagnosis of acute
kidney injury, this should not be mentioned in the query. Attributing the decreased urine output to acute
pyelonephritis is also a leading question. The compliant query would simply give the physician an
opportunity to add any additional diagnoses indicated by the decreased urine output.
Question # 11
What are the types of remotely hosted EHRs?
A: Subsidized, dedicated, and cloud based B: On premises and cloud based C: Dedicated. on premises, and cloud based D: Off premises and cloud based
Answer: A Explanation: Per the U.S. Department of Health and Human Services (HHS) Cybersecurity Program, HER systems may
be physician hosted or remotely hosted. Remotely hosted EHRs are of three types: subsidized, dedicated,
and cloud based.
Question # 12
Which one of the following is an example of healthcare abuse?
A: Deliberate falsification of medical records by misuse of copy and paste B: Intentional alteration of a record to support higher levels of care than that that provided C: Repeated submission of claims with the same coding error due to outdated knowledge D: Nonaccidental use of electronic health record (EHR) templates to document services that were not provided
Answer: C Explanation:
The repeated submission of claims with coding and billing errors, even when unintentional, is considered
medical abuse. (Coders have a responsibility to keep up to date with changes in coding guidelines and
payer-specific guidelines.) The other choices listed are all examples of medical fraud.
Question # 13
Which one of the following is considered a hospital-acquired condition (HAC)?
A: Central line infection, present on admission B: Catheter-associated UTI as the principal diagnosis C: Clostridium difficile infection (CDI), not present on admission D: COVID-19 as a secondary diagnosis, present on admission
Answer: C Explanation: To be considered an HAC, a condition must not have been present on admission, but it must have been
acquired during the hospital stay. Since a principal diagnosis must be present at admission, an HAC cannot
be the same as the principal diagnosis for that stay. Of the options given, only the CDI is not present on
admission. CDI is on the CMS list of hospital-acquired infections.
Question # 14
A newborn sustained a fracture of the clavicle during a difficult hospital delivery. What is the POA indicator
for this birth injury?
A: N, because the mother was already admitted at the time the injury occurred. B: U, because we are not told at what point during delivery the injury occurred. C: Y, because conditions that occur during delivery are considered to be present on admission. D: None, because conditions that occur during delivery are exempt from POA reporting.
Answer: C Explanation:
Newborns are not considered admitted until after birth, according to ICD-10-CM guidelines (Appendix 1).
We are to assign a POA indicator of Y for conditions that occur during delivery. The mothers admission is
not relevant here and neither is the specific point in the delivery at which the injury occurred. Only
conditions on the list of POA-exempt codes are exempt from POA reporting.
Question # 15
Which one of the following statements about assigning POA indicators is true?
A: They are not required for external cause of injury codes. B: They must be assigned immediately after patients are admitted. C: If the documentation is unclear, coders must use their best judgment. D: This field is only left blank when a condition is exempt from POA reporting.
Answer: D Explanation: POA indicators should be assigned to principal diagnoses, secondary diagnoses, and external cause of
injury codes. The field is only left blank when a diagnosis is on the list of ICD-IO-CM POA-exempt codes.
There is no set time frame for determining if a condition was present on admission: The responsibility for
that determination rests with the provider, not the coder. If the documentation is incomplete or unclear, a
coder must query the provider.
Question # 16
Which one of the following is true about computer-assisted coding?
A: It improves coder productivity. B: It speeds up coding but increases errors. C: It is not developed enough for widespread use. D: It is more accurate than unassisted coding but much slower.
Answer: A Explanation: Computer-assisted coding improves coder productivity by accelerating the coding process, decreasing errors, and increasing efficiency. Although new technologies are continually being developed, computer-assisted coding is widely used.
Question # 17
What is true of recognized security practices (RSPs) under the 2021 amendment of the Health Information
Technology for Economic and Clinical Health (HITECH) Act?
A: Their implementation is mandatory. B: If they have been in place for six months, RSPs may reduce penalties for a data breach. C: They are industry-recognized best practices for protecting sensitive health data. D: Failure to implement them may result in fines.
Answer: C Explanation: RSPs are industry-recognized best practices for safeguarding sensitive health data. Under the 2021
HITECH Act amendment, RSPs may help decrease penalties when a covered entity or business associate
experiences a data breach. RSPs can only be considered if they were in place for the preceding 12
months. The implementation of RSPs is voluntary, and there are no fines for not having one in place.
Question # 18
Which one of the following is true about procedure-to-procedure (PTP) edits?
A: They are based on services provided by the same physician to the same beneficiary on the same day. B: They indicate when a modifier needs to be applied to one code in a procedure pair. C: They indicate whether a pair of procedures is considered medically necessary by Medicare. D: They indicate when to schedule two procedures on different days to get maximum reimbursement
Answer: A
Explanation:
The Medicare NCCI Coding Policy Manual states that PTP edits are based on services provided by the
same physician to the same beneficiary on the same date of service. Modifiers should only be used if
indicated by the clinical circumstances and not simply to bypass a PTP edit. NCCI does not establish
medical necessity, and it specifically disallows performing procedures on different dates simply to avoid
claim edits.
Question # 19
A patient is admitted with altered mental status. His physician's notes indicate that labs drawn at admission
show elevated ammonia and abnormal liver function, supporting a diagnosis of hepatic encephalopathy.
Additionally, a diagnosis of hepatic cirrhosis is documented, but this is not linked in the progress note to any
specific diagnostic study or examination finding. What is the next best step for a clinical validation
professional?
A: Create a (tactful) clinical validation query into whether the provider made a wrong diagnosis. B: Collaborate with denials management so that the diagnosis is not coded if it is at high risk for denial. C: Send a clinical validation query to the hepatology team because this is a liver disease. D: Check if there is a diagnostic study, such as imaging or a pathology report, indicating cirrhosis.
Answer: D
Explanation:
A clinical validator's task is to determine whether a diagnosis is clinically valid based on the totality of the
medical records, so it would not be appropriate to query the provider before looking for clinical indicators
that support a diagnosis of cirrhosis, such as imaging or pathology reports.
The purpose of a clinical validation query is not to question the provider's judgment (even tactfully), but to
help clarify what clinical evidence was used in coming to a diagnosis. Queries should be sent to the treating
physician(s). According to AHIMA's Standards of Ethical Coding, it would be inappropriate to send a query
to a provider who is not providing direct care.
Collaborating with denials management is a reasonable step as part of a secondmy validation process, not
for the reason listed. A diagnosis should not be dropped simply because it has a high risk of denial, but the
staff members managing denials do have a role in advising which documentation deficiencies tend to be
associated with denials. This could be part of a secondary validation process but would not be the most
appropriate next step.
Question # 20
Which one of the following is true about compliance plans?
A: The Office of Inspector General enforces them as being mandatory for all providers. B: They are only useful for preventing audits. C: Oral or written policies are equally effective. D: They decrease billing errors and enable more accurate payments.
Answer: D Explanation: The Office of Inspector General provides compliance plan guidance for provider practices. Per that
guidance, an effective compliance plan should be in written form. Program participation is voluntary. In
addition to decreasing billing errors and inaccurate payments, compliance plans lessen the chance of an
audit. The Office of Inspector General Work Plan identifies possible compliance issues that it intends to
focus on.
Question # 21
A coder observes that the HPI for a patient's follow-up visit is identical to that for her two previous
encounters, despite different reasons being listed for each visit. This is an example of:
A: Duplicate medical records B: Cloning C: Provider burnout D: Query fatigue
Answer: B Explanation: The term cloning refers to duplicating the content of a prior note into a new note without documenting the
specifics of the current encounter. This may result in misrepresentation of the patient's current clinical
conditions. Duplicate medical records are the duplication of a patient's entire account within a medical
record system, and they usually result from failure to accurately identify a patient Provider burnout may
contribute to noncompliant documentation such as cloning. Query fatigue is unrelated to cloning
Question # 22
When is it ethical to use information from a prior encounter in a clinical validation query?
A: When applying new clinical guidelines to previous encounters. B: When establishing a cause-and-effect relationship between a prior condition and a current one. C: When checking clinical criteria for prior diagnoses so that they can be listed in the current encounter. D: It is never ethical to use information from a prior encounter in a query.
Answer: B Explanation: According to AHIMA's Guidelines for Achieving a Compliant Query Practice, information from a prior encounter may be used in a query only when it is relevant to the current encounter. One example of this is when establishing a cause-and-effect relationship. Reviewing previous records without an existing reason in the current encounter is known as mining, and queries generated this way are considered noncompliant. Queries should not be based solely on information from a previous encounter, so a change in clinical guidelines or a desire to recheck prior diagnoses is an insufficient justification for a query. If the current encounter indicates a need, using information from a prior encounter would not be unethical.
Question # 23
Which one of the following choices is unethical when constructing a query?
A: Offering one multiple-choice answer option that is clinically credible B: Including all relevant supporting clinical indicators C: Using clear and concise wording that also allows for accurate coding D: Keeping any diagnoses that have not been documented out of the title
Answer: A Explanation: All options listed in a query should be clinically credible—not just one. Listing all relevant clinical indicators
for an encounter, using clear and concise language that allows for accurate coding. and excluding
diagnoses not previously documented from the title all constitute best practices for clinical validation
queries.
Question # 24
Which one of the following situations is NOT a reason to query?
A: Documentation in the medical record does not show a clear reason for an encounter. B: Amore specific diagnosis code exists, but no supporting clinical indicators for this code are in the record. C: A signed ancillary note contains a diagnosis not addressed by the provider. D: It is unclear from the record whether a condition was present on admission.
Answer: B
Explanation: According to ICD-10-CM guidelines, diagnosis codes must be reported to the highest specificity that is
supported by the documentation. If the documentation does not contain supporting clinical indicators for a
more specific diagnosis, the most appropriate valid code that is supported must be selected. The other
options all indicate situations in which queries are indicated
Question # 25
What is the aim of medical necessity edits?
A: To prevent expensive procedures from being overused by providers B: To deny payment when an Advance Beneficiary Notice of Noncoverage ([ABN] Form CMS-R- 131) was not obtained C: To help a Medicare administrative contractor create national coverage determinations D: To ensure that services are paid only for preapproved diagnoses that are medically necessary'
Answer: D
Explanation:
Medicare defines services or supplies as being medically necessary if they are "needed to diagnose or
treat an illness, injury, condition, disease or its symptoms" and if they "meet accepted standards of
medicine." Medical necessity edits are not based on the relative cost of services or supplies but on whether
the diagnoses in a claim support their medical necessity. An ABN does not determine whether a claim is
payable, but a properly obtained ABN allows a patient to be billed for services denied by Medicare.
Medicare administrative contractors use national coverage determinations to determine regional policies
called local coverage determinations.
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