This course familiarizes the student with coding and classification systems used in health information management. Emphasis is on inpatient coding and classification utilizing ICD-10-CM/PCS. Course work focuses on the official coding guidelines and use of the two volumes of ICD-10-CM and ICD-10-PCS. The laboratory component of the course emphasizes the use of computer-based coding software (encoder) to assign diagnostic and procedural codes by abstracting information from patient records. Students learn to determine the DRG for each patient record coded. Additional classifications are briefly studied stems such as DSM-5, ICD-O, and SNOMED-CT.

This course provides the student with an overview of the guidelines, rules, and terms for the Current Procedural Terminology (CPT) coding classification and the application of those rules to code patient services. A major focus of the course is to prepare the students to correctly code using the CPT manual. Students will learn how to recognize CPT symbols, use the CPT Index, use modifiers, and read an operative report. A laboratory component will allow students to develop skills in coding using computer software and sample health records. Co-requisite MDA 101.

The emphasis of this course is on coding procedures using ICD-10-PCS classification system. The course also contains advance coding of diagnosis using ICD-10-CM. The history, structure, and organization of ICD-10-PCS is reviewed and reinforced with exercises and homework assignments. The sixteen sections of ICD-10-PCS are defined along with their application in coding procedures. The values of each character of a code from each section is applied to create surgical codes. The Tables, Index, and the list of codes are used to access the root operation tables and the construction of a surgical code. The use of the Index and Table conventions are described and used to construct procedural codes. The Medical and Surgical section are emphasized in the courses with the thirty-one body system values and its root operations, body parts, approaches, devices and qualifiers. The organization and classification of the ancillary section such as imaging, nuclear medicine, radiation oncology, physical rehabilitation and diagnostic audiology, mental Attachment II health and substance abuse treatment are studied and coded. In addition, students conduct case mix analysis, identify severity of illnesses and create reports on coding quality monitors.

This course is a continuation of CPT/HCPCS Coding I, providing the student with the knowledge and skills to code ambulatory procedures and services by applying guidelines, rules and terms for the Current Procedural Terminology (CPT) coding classification. CPT/HCPCS codes are used for reporting services and procedures performed by physicians and hospital based ambulatory departments. A major focus of the course is to prepare the students to correctly code case studies using the CPT manual or computer based encoder. Students demonstrate the ability to correctly use the CPT book or CPT coding software by recognizing CPT symbols, the use of CPT Index, use of modifiers and how to read an operative reports. Attachment III Students also learn how to use and report codes from the Evaluation and Management (EandM) section, Surgery section, Radiology section and Medicine section of CPT manual. A laboratory component allows students to develop skills in coding using computer software and sample health records.

The pathophysiology component of this course places emphasis on the disease process affecting the human body course. The etiology and pathogenesis of diseases are described in the course with the application of diagnostic procedures and patient care. The pathology and the underlying principles of the following human systems are presented in this course: inflammation, diseases of the immunity, neoplasia, genetic and developmental diseases, fluid and hemodynamic disorders, cardiovascular pathology, respiratory and gastrointestinal pathology, renal and endocrine pathology, skeletal, male and female reproductive pathology, endocrine systems, the skin, bones and joints, muscles and the nervous system. The second component of the course is the study of pharmacology and diagnostic testing. Students will be able to define adverse reaction to drugs, interactions, and contraindications. Attachment IV Differentiation among drug names, generic names, trade names, and chemical names are discussed. Students are able to identify drugs according to body systems. Classes of drugs that will be covered in this class are: Adrenergic drugs affecting the neurological system, Psychiatric drugs, anticonvulsants and antiparkinsonism drugs, anesthetic drugs, anaglesics and antagonistic drugs, antihistamines, Bronchodilators, Antineoplastic Drugs, Cardiovascular Drugs, Musculoskeletal and Anti-inflammatory Drugs, antihypertensive drugs, antidiabetic drugs, antibacterial drugs, anti-infective drugs, and diuretics. The laboratory component allows students to reinforce didactic content.

This course prepares the students for working as a medical biller. Students learn the medical and ethical concepts of billing as well as computer skills necessary to construct a clean claim. Students see the continuum of the entire process from medical coding, medical billing, submission of claims and the appeals process.

This course is a comprehensive study of health information and reimbursement. The health information component of the course includes health record documentation, the electronic health record, healthcare delivery systems, and information technology and systems. Data retrieval, data security and data integrity processes are identified and evaluated. The second focus of the course is on the basic concepts and principles of healthcare reimbursement in healthcare settings and managed care. The current healthcare insurance programs both commercial and government sponsored are described in the context of the United States' health delivery system. Students also learn the management of the revenue cycle. In the laboratory portion of the course, students gain knowledge of and skills in the use of electronic health records. This course requires students to purchase AHIMA Virtual Lab software to complete the laboratory exercises.

The professional practice experience (PPE) is a supervised practical experience in a health information management department in a acute and/or non-acute healthcare facility. The focus of the PPE is to provide the student with practical experience in ICD-10CM/PCS and CPT/HCPCS coding, computerized information systems, billing and reimbursement, and the electronic health record. Students will have supplemental practice through practice exercises to enhance all aspects of coding areas.

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