Read the Case Carefully
- Skim the entire scenario once to understand the big picture (inpatient, outpatient, ED, surgical, etc.).
- Underline or highlight key clinical details:
- Primary diagnosis
- Secondary diagnoses/comorbidities
- Procedures performed
- Patient status (new vs. established, inpatient vs. outpatient)
- Provider specialty
Tip: Watch for words like “complication,” “rule out,” “history of,” “secondary to,” as they guide coding choices.
Identify the Main Reason for the Encounter
- Ask yourself: Why is the patient being seen/admitted?
- Assign the principal diagnosis first (ICD-10-CM).
- For surgical cases, identify the main procedure and its purpose (CPT/PCS).
Example: If a patient is admitted for pneumonia with a history of COPD, pneumonia is the principal diagnosis; COPD is a secondary diagnosis.
Break Down the Scenario
Create a mini-outline:
- Diagnoses → List all conditions mentioned (active, chronic, or ruled out).
- Procedures → Circle/underline all tests, treatments, and surgeries.
- Medications/Treatments → Note if they support a diagnosis (e.g., insulin = diabetes).
- Complications/Findings → Capture sequelae, post-op conditions, or abnormal test results.
Apply Coding Guidelines
- ICD-10-CM
- Follow Official Guidelines (laterality, acute vs. chronic, sequencing rules).
- Remember “Code first,” “Use additional code,” and “Excludes1/Excludes2.”
- CPT / HCPCS
- Pay attention to modifiers (e.g., 25, 59, 76).
- Differentiate bundled vs. separately reportable procedures.
- PCS (if inpatient)
- Use root operations correctly (Excision vs. Resection, Insertion vs. Replacement).
- Capture approach, device, and anatomical site.
2026 ICD-10 guildelines https://www.cms.gov/files/document/fy-2026-icd-10-cm-coding-guidelines.pdf
Sequence Correctly
- Start with principal diagnosis → then secondary diagnoses in order of significance.
- For procedures, report the primary surgery first, then add-on or secondary codes.
Sequencing in Medical Coding
Check for Exam “Traps”
- Rule-out diagnoses (do not code as confirmed unless exam guidelines allow).
- Multiple procedures (make sure to assign all, but avoid unbundling).
- Modifiers (ensure correct use for repeat, staged, and discontinued procedures).
Manage Your Time
- Don’t get stuck on one long case.
- Use the “30-second rule”: If you can’t locate the correct code quickly, mark it and return later.
- Answer easier questions first to build confidence.
Time Management for the AAPC CPC Exam https://codingclarified.com/time-management-for-the-aapc-cpc-exam/
Practice Strategy
- Work through full case studies regularly.
- Simulate timed exam conditions (5–7 minutes per long scenario).
- Use official coding guidelines as you practice—just like on exam day.
Official CPC® Certification Study Guide https://www.aapc.com/shop2/study-guides/cpc-study-guide.aspx
AAPC Practice Exams tps://www.aapc.com/shop2/practice-exams.aspx#cpc
Quick Case Example (Mini-Practice)
Case:
A 67-year-old male was admitted for chest pain. Workup revealed acute NSTEMI. Patient has type 2 diabetes and hypertension. A cardiac catheterization with stent placement was performed.
Steps:
- Principal Dx: NSTEMI (I21.4)
- Secondary Dx: Diabetes (E11.9), Hypertension (I10)
- Procedure: Cardiac cath with stent → CPT 92928
- Possible Modifier: If multiple vessels, add modifier or second CPT as appropriate
AAPC Exam breakdown https://www.aapc.com/certifications/cpc/taking-the-cpc-exam
Abstracting from the EHR https://codingclarified.com/ehr-abstracting/
Process of Elimination for the AAPC CPC Exam https://codingclarified.com/process-of-elimination-for-the-aapc-cpc-exam/
CPT Medical Modifiers https://codingclarified.com/cpt-medical-modifiers/
Medical Coding Anatomical Modifiers https://codingclarified.com/medical-coding-anatomical-modifiers/
Are You Prepared For The AAPC CPC Exam https://codingclarified.com/prepared-for-aapc-cpc-exam/
CPC Tips https://codingclarified.com/tips-to-pass-the-aapc-cpc-exam/
Prep your Medical Coding Manuals for AAPC CPC Exam
https://codingclarified.com/prep-your-medical-coding-manuals-for-aapc-cpc-exam/
AAPC Online Exam Review https://www.aapc.com/shop2/cpc-online-exam-review.aspx