HEALTH INFORMATION TECHNOLOGY COURSE SYLLABUS SPRING 2006

Transcription

1 HEALTH INFORMATION TECHNOLOGY COURSE SYLLABUS SPRING 2006 HIT 101B Section 801 CURRENT PROCEDURAL TERMINOLOGY (CPT4) D01 Sat 8:00 am - 5:50 pm INSTRUCTOR Peggy M. Perkins-Arnot, RHIA, CCS-P (w) peggy_perkins@ccsn.edu Internet site: PREREQUISITES: HIT 118B or MOA 108B or language of medicine class offered by GBC CREDITS: 3 COURSE DESCRIPTION: This course is designed to be an introduction to outpatient procedural coding. The student will be introduced to CMS's HCPCS three-level coding system, including basic coding guidelines and practice using CPT-4. The course is designed to meet the needs of the medical record practitioner in hospital medical record/billing departments, physician's offices, and insurance companies for both reimbursement and research needs. OBJECTIVES: At the conclusion of this course, the student will be able to complete the goals outlined in this syllabus with at least 70% accuracy. See the end of this syllabus for complete goals and objectives. TEXTBOOKS REQUIRED: Smith, Gail I., MA, RHIA, CCS-P. Basic CPT/HCPCS Coding 2006 American Medical Association. CPT-4 Physician's Procedural Terminology Any medical dictionary Some handouts must be accessed on the internet at ACADEMIC DISHONESTY Honesty is required of all students. Dishonesty is an offense that may include, but is not limited To, copying from another student on a test, cribbing, plagiarism, and falsifying academic and/or clinical records. Dishonesty diminishes the quality of scholarship, misrepresents professional knowledge and integrity, and places professionals and patients at risk. This is a Zero Tolerance policy. If academic dishonesty is discovered in this class, the student will receive a grade of F for the class. EVALUATION Grades will be calculated based on the percentage of points earned of the total points possible. Following is an estimate of the number of points possible. You may ask for your earned points compared to total points at any time during the class. Important note: The instructor has the option of changing this point list at any time during the class. Actual totals will vary due to changes in number of tests and points per exam and schedule changes. 5 points may be earned for each morning or afternoon class attended for a possible total of 60 points Homework assignments will be from 5 to 10points each (possible total will vary from 40 to 75 points) Up to 50 points may be earned for the E&M special project. Approximately 120 points may be earned for post-chapter quizzes. Up to 50 points may be earned for the Final.

2 Remember: Total points may vary due to changes in the schedule. 2 A % A % B % B 83-86% B % C % C 73-76% C % D % D 63-66% D % F 0-59% ATTENDANCE 1. IMPORTANT!! Part of your grade will be based on attendance. You MUST sign the sign-in sheets for both morning and afternoon indicating your presence to obtain attendance points. NO EXCEPTIONS. 2. You are expected to arrive ON TIME or early and stay for the full time. 3. Three (3) tardies or early departures greater than 15 minutes and less than 30 minutes without instructor approval equals 1 absence. (10 points will be deducted from your attendance points.) 4. An absence of more than 30 minutes in any day without instructor approval will be considered a complete absence and NO attendance points may be earned for that day. 5. IMPORTANT NOTE: In the event of a difference between GBC and CCSN schedules, the student will be expected to adhere to the CCSN schedule. MAKE UP TESTS Make-up tests are discouraged. 1. All make up tests will be given on one instructor-designated day only. 2. Every make up test will receive a 10% deduction in the score you earn. 3. No make-up tests will be given during finals week. MISSING ATTENDANCE OR LATE HOMEWORK 1. If you miss a scheduled class or fail to sign a sign-in sheet, the attendance points for that morning or afternoon will be zero: NO EXCEPTIONS. 2. IMPORTANT!! If your assignment is incomplete or late, you will only receive half of the possible points available for that assignment or worksheet. DISABILITY RESOURCE CENTER If you are a CCSN student and have a documented disability that may require assistance, you will need to contact the Disability Resource Center located in the Student Service Center on each campus. Cheyenne phone number is , Henderson, and West Charleston is CELL PHONES/BEEPERS Cell phones and/or beepers must be turned off or set to vibrate during class or lab time. Do not take calls during class time unless it is an emergency. SPRING 2006 Monday Wednesday class (Revised Mar 14, 2006) 2

3 COURSE OUTLINE 3 WHAT YOU MUST DO BEFORE CLASS CLASS DATE WHAT WE WILL DO IN CLASS Purchase books Check the web site every week 03/18/2006 ORIENTATION LECTURE Chapters 1, 2, 10, and 11 Third Party Reimbursement Introduction to CPT 4 & HCPCS Basic Coding Guidelines for Outpatient Services 03/18/2006 LECTURE Understanding How to Read a Code 1. READ Chapters 1, 2, 10, and 11 for quiz 2. STUDY for quiz 3. READ Chapter 7 for lecture 4. DOWNLOAD and print all online materials below Evaluation and Management (Note: There are a lot of printouts here. Please don t try to do this all at one time.) 03/25/2006 NO CLASS CCSN SPRING BREAK 04/01/2006 QUIZ 1 Introductory material and Chapters 1, 2, 10, and 11 LECTURE Chapter 7 - E&M Coding Defining the terms new patient, established patient, subsequent or followup, inpatient, outpatient, place of service, and patient status. Key Elements: History, Examination, Medical Decision Making Time as an element Identifying the number of elements necessary to select a certain E&M code. 1. BEGIN E&M Project 2. DOWNLOAD AND COMPLETE E&M. (10 pts.) 3. READ Chapter 3 04/01/ /08/ /08/2006 LECTURE AND PRACTICE: Applying either the Table method or the Three-finger method to correctly assign CPT codes for E&M services when levels of History, Exam, Medical Decision Making and Time are documented by a physician. REVIEW E&M LECTURE Using DGs to select a level of Hx, Ex, and MDM E&M Coding Practice: Using guidelines to determine what type of E&M code to select. (Example: Outpatient, Inpatient, Consultation, Critical Care, etc.) and using DGs to select a code. LECTURE Modifiers

4 WHAT YOU MUST DO BEFORE CLASS CLASS DATE WHAT WE WILL DO IN CLASS 1. E&M Midterm Project DUE (50 pts) 4 04/15/2006 REVIEW modifier 2. COMPLETE Modifier (10 pts.) 3. STUDY for Quiz 4. READ Chapter 4, Pages READ Surgery guidelines and guidelines in Integumentary and Musculoskeletal Systems (CPT Book) 6. DOWNLOAD and print online material Anesthesia and Basic Surgery Overheads 7. DOWNLOAD and print online material Integumentary and Musculoskeletal Overheads 8. DOWNLOAD and print Integumentary and Musculoskeletal System 04/15/2006 QUIZ 2 Chapters 7 and 3 and related E&M lectures Anesthesia Major Surgery Guidelines Integumentary System Musculoskeletal System GROUP PRACTICE: Work on Integumentary and Musculoskeletal System 1. STUDY for Quiz 2. DOWNLOAD, PRINT, and READ online material Respiratory - Special Senses 3. READ Chapter 4, Pages READ guidelines in Respiratory, Cardiovascular, and Digestive Systems (CPT Book) 5. DOWNLOAD and print related Systems 04/22/ /22/2006 REVIEW QUIZ 3 Chapter 4 - Basic Surgery, Integumentary, and Musculoskeletal Systems Respiratory System Cardiovascular System Surgery Digestive System Mediastinum and Diaphragm Urinary System (if time permits) GROUP PRACTICE: Work on related System.

5 WHAT YOU MUST DO BEFORE CLASS CLASS DATE WHAT WE WILL DO IN CLASS 5 1. COMPLETE not completed in class last week. (10 pts.) 2. STUDY for Quiz 3. READ guidelines in Urinary, Male Reproductive, Hemic/lymphatic, Endocrine, Nervous, Eye, and Auditory Systems (CPT Book) 4. READ Chapter 4 Pages DOWNLOAD and print related 04/28/ /28/2006 REVIEW QUIZ 4 Chapter 4 Respiratory, Cardiovascular, and Digestive systems Urinary System (if not covered last week) Male Reproductive Systems Female Reproductive System Hemic/lymphatic systems Endocrine system Nervous system Eye and ocular adnexa Auditory system GROUP PRACTICE: Work on related 1. COMPLETE any not completed in class last week (10 pts.) 2. STUDY for Quiz 3. READ Chapters 5, 6, and 8 4. READ Radiology, Laboratory, and Medicine guidelines in CPT book 5. DOWNLOAD, print, and read online material Radiology, Laboratory, Pathology and Medicine 6. DOWNLOAD and print Radiology worksheet 7. DOWNLOAD and print Lab/Path worksheet 05/06/ /06/2006 REVIEW QUIZ 4 Chapter 4 - Digestive system through Auditory System LECTURE Chapter 5 Radiology Chapter 6 - Laboratory/Pathology Chapter 8 Medicine GROUP PRACTICE: Work on related FINAL DISTRIBUTED: The final will be a takehome, but keep in mind that it MUST be completed by you (no help from friends, classmates, or professionals). The final is due on Monday, May 8, by 5 pm. You may the answers, fax the answer sheet, or have GBC staff forward the answer sheet to me with the time and date they received it stamped on the answer sheet.

6 GOALS This class has been developed to be consistent with selected goals of AHIMA=s CCA, CCS-P, and HIT credentials. The class goal is identified in the goal table by a class goal number, a class goal description, the AHIMA credential it relates to, the AHIMA content area, and the AHIMA goal that the class goal fills. 6 CREDENTIAL KEY: RHIT = Registered Health Information Technologist CCA = Certified Coding Associate; CCS- P = Certified Coding Specialist - Physician-based AHIMA CONTENT AREAS RHIT I: Healthcare Data: CCA II: Clinical Classification Reimbursement Methodologies CCS-P I. Health Information Documentation CCS-P II. Coding CCS-P III. Reimbursement Methods and Regulatory Guidelines CCS-P IV. Data Quality OBJECTIVE TABLE Objective # Objective AHIMA CONTENT AREA 1 Understand the coding process CCS-P II.4 Assign CPT code(s) for procedures and/or services rendered during the encounter Interpret CPT and HCPCS II guidelines, format, and instructional notes. Apply knowledge of CPT format to locate codes. Demonstrate the appropriate way to read a CPT code. Understand CPT modifiers and their use. CCS-P II.10 Append modifiers to procedure or service codes when applicable Apply understanding of the key elements (components) to code E&M services. Select a key element (component) using chart documentation. (History, Exam, and Medical Decision Making. Understand the concept of global packages, unbundling, and edit pairs. CCS-P II.5 Assign code to identify Evaluation and Management (E/M) service. CCS-P IV.2 Validate assigned Evaluation and Management codes based on health record documentation using the E/M guidelines. CCS-P III.1 Apply global surgical package concept to surgical procedures.

7 Objective # Objective AHIMA CONTENT AREA 9 Correctly assign CPT codes for services and supplies. 7 RHIT 1C.1: Assign procedure codes using CPT/HCPCS. CCS-P I.2 Interpret health record documentation to identify procedures or services for code assignment CCS-P I.4 Determine if sufficient clinical information is available to assign one or more procedure or service codes CCA II.1 Assign diagnosis/procedure codes using CPT/HCPCS CCS-P II.8 Code for the professional vs. technical component when applicable CCS-P II.6 Recognize if an unlisted code must be assigned 10 Validate coding accuracy using clinical information found in the health record. RHIT IA.4: Validate coding accuracy using clinical information found in the health record CCA II.2 Validate coding accuracy using clinical information found in the health record CCS-P I.5 Consult with physicians or other healthcare providers when additional information is needed for coding and/or to clarify conflicting or ambiguous information CCS-P IV.1 Validate assigned procedure codes supported by health record documentation CCS-P IV.8 Determine educational needs for physicians and staff on reimbursement and documentation rules and regulations CCS-P IV.9 Participate in the development of coding and billing policies and procedures for reporting professional services

8 8 The student will be introduced to the Standards for AHIMA Physician-based Coding Competencies including: TASKS DATA IDENTIFICATION 1 Read and interpret visit documentation to identify code3able diagnoses and procedures for data capture and billing. 2 Read and interpret medical record documentation to identify all diagnoses, conditions, problems, or other reasons for the outpatient encounter and all services and procedures performed during that visit. 3 Assess the adequacy of medical record documentation to ensure that it supports the codes assigned. TASKS CODING GUIDELINES 4 Understand the use and function of modifiers in CPT. 5 Apply knowledge of CPT guidelines, format, and notes to locate and correctly sequence codes for all services and procedures performed during the encounter. 6 Confirm Evaluation and Management codes based upon medical record documentation using the E/M guidelines. 7 Demonstrate knowledge of coding guidelines for technical versus professional component. 8 Recognize when an unlisted CPT procedure must be used. 9 Apply regulatory agency guidelines (i.e. HCFA) to coding principles so that codes are assigned correctly to each visit. 10 Observe guidelines on bundling and unbundling. 11 Have knowledge of the global surgical package and its components.