School of Health Sciences HEALTH INFORMATION TECHNOLOGY

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1 School of Health Sciences HEALTH INFORMATION TECHNOLOGY Course: HIT Basic Procedure Coding Credit Hours: 3cr hours Instructor: TBA Office Phone: Division of Allied Health (801) Office Hours: TBA PREREQUISITES: None RECOMMENDED CO-REQUISITES: HIT 1010, HIT 1020, HIT 1040, and HIT 1100 REQUIRED TEXT: Step-by-Step Medical Coding, Current Edition, by Carol J. Buck, Saunders Workbook for Step-by-Step Medical Coding, Current Edition, by Carol J. Buck, Saunders Current Procedural Terminology, Current Edition, by American Medical Association HCPCS Level II, Current Edition, by Carol J. Buck, Saunders COURSE DESCRIPTION Introduction and practice with Current Procedural Terminology (CPT) HCPCS for optimal reimbursements, as practiced in the medical setting. Course material is presented in an online lecture format as well as the presentation and discussion of patient care scenarios to enhance the learning process. Media materials, coding resources, CD and textbook based programs are used to provide patient case reports and operative procedures. COURSE FOCUS The course focus is learning the basic coding rules for CPT Level I and HCPCS Level II procedural coding systems and then applying the rules to code patient procedures and services. In addition, the history of the National level codes is reviewed. (To present this course requires anatomy, physiology, pathophysiology and terminology to be sequenced concurrently so that the specific system/material is presented along with the coding of the system). 1

2 Methods include online discussion and lectures format, demonstrations and media presentations. The following list of Course Objectives further describes this focus. COURSE OBJECTIVES UNIT #1 CPT and HCPCS CHAPTER #13 Introduction to the CPT and Level II National Codes (HCPCS) Week One Identify the uses of the CPT manual. Name the developers of the CPT manual. Identify placement of CPT codes on the CMS-1500 insurance form. Know the importance of using the current-year CPT manual. Recognize the symbols used in the CPT manual. Identify the content of the CPT appendices. Locate the major sections found in the CPT manual. Interpret the information contained in the section Guidelines and notes. Describe the CPT code format. Append modifiers. Describe what is meant by unlisted procedures/services. Review Category II and III CPT codes. State the purposes of a special report. Locate terms in the CPT index. Demonstrate the ability to assign HCPCS codes. List the major features of Level II National Codes, HCPCS. UNIT #2 MODIFIERS CHAPTER #14 Modifiers Week Two Recognize modifiers. Understand the purpose of modifiers. Assign Increased Procedural Services modifier -22. Assign Unusual Anesthesia modifier -23. Assign Unrelated E/M Services by the Same Physician During a Postoperative Period modifier -24. Assign Significant Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service modifier -25. Assign the Professional Component modifier -26. Assign Mandated Services modifier -32. Assign Preventive Services modifier -33. Assign Anesthesia by Surgeon modifier -47. Assign Bilateral Procedure modifier -50. Assign Multiple Procedures modifier -51. Assign Reduced Services modifier -52. Assign Discontinued Procedure modifier -53. Assign Surgical Care Only modifier -54. Assign Postoperative Management Only modifier -55. Assign Preoperative Management Only modifier -56. Assign Decision for Surgery modifier

3 Assign Staged or Related Procedure or Service by the Same Physician During the Postoperative Period modifier -58. Assign Distinct Procedural Service modifier -59. Assign Two Surgeons modifier -62. Assign Procedure Performed on Infants Less than 4 kg modifier -63. Assign Surgical Team modifier -66. Assign Repeat Procedure or Service by Same Physician modifier -76. Assign Repeat Procedure by Another Physician modifier -77. Assign Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period modifier -78. Assign Unrelated Procedure or Service by the Same Physician During the Postoperative Period modifier -79. Assign Assistant Surgeon modifier -80. Assign Minimum Assistant Surgeon modifier -81. Assign Assistant Surgeon (When Qualified Resident Surgeon Not Available) modifier -82. Assign Reference (Outside) Laboratory modifier -90. Assign Repeat Clinical Diagnostic Laboratory Test modifier -91. Assign Alternative Laboratory Platform Testing modifier -92. Assign Multiple Modifiers modifier -99. UNIT #3 EVALUATION AND MANAGEMENT SERVICES CHAPTER #15 Evaluation and Management (E/M) Services Week Three Identify and explain the three factors of E/M code assignment. Differentiate between a new and an established patient. Differentiate between an inpatient and an outpatient. Explain the levels of E/M service. Review the key components. Analyze the key component history. Analyze the key component examination. Analyze the key component in medical decision making. List contributory factors. Analyze code information. Analyze the types of E/M codes. Demonstrate the ability to code E/M services. Identify CMS Documentation Guidelines. UNIT #4 PROCEDURES CHAPTER #16 Anesthesia Week Four Define types of anesthesia. Explain the format of the Anesthesia section and subsections. Understand the anesthesia formula. Demonstrate the ability to code anesthesia services. Identify use of other modifiers with anesthesia codes. CHAPTER #17 Surgery Guidelines and General Surgery Week Four 3

4 Understand the Surgery section format. Locate notes and Guidelines in the Surgery section. State the uses of the unlisted procedure codes. Interpret elements of a special report. Examine the separate procedure designation. Analyze the contents of a surgical package. Determine the contents of the General subsection. CHAPTER #18 Integumentary System Week Five Describe the format of the Integumentary System in the CPT manual. Identify the elements of coding Skin, Subcutaneous, and Accessory Structures services. Review the main services in Nails, Pilonidal Cyst, and Introduction. Identify the major factors in Repair. State the important coding considerations in destruction, Mohs micrographic surgery, and breast procedures. Demonstrate the ability to code integumentary services and procedures. CHAPTER #19 Musculoskeletal System Week Six Differentiate between fracture and dislocation treatment types. Understand types of traction. Identify services/procedures included in the General subheading. Analyze cast application and strapping procedures. Understand elements of arthroscopic procedures. Demonstrate the ability to code musculoskeletal services and procedures. CHAPTER #20 Respiratory System Week Seven Differentiate between services reported with codes from the Respiratory subsection and those reported with codes from other subsections. Explain the effects of extent and approach when reporting endoscopy respiratory procedures. Identify highlights of nasal procedure coding. Analyze the codes to report services to the accessory sinuses. Categorize the codes in the Larynx subheading. Explain the structure of the trachea/bronchi codes. Distinguish the difference between the codes assigned to report lungs and pleura services, and procedures. Demonstrate the ability to code respiratory services and procedures. CHAPTER #21 Cardiovascular system Week Eight Understand cardiovascular services across three sections Surgery, Medicine, and Radiology. Review cardiovascular coding terminology. Recognize the major differences in the subheadings of the Cardiovascular subsection. Define rules of coding cardiovascular services when codes from the Medicine section are used. Identify the major rules of coding cardiovascular services using the Radiology section codes. Demonstrate the ability to report Cardiovascular services. 4

5 CHAPTER #22 Hemic, Lymphatic, Mediastinum, and Diaphragm Using Week Eight Review the Hemic and Lymphatic Systems subsection format. Understand the Hemic and Lymphatic Systems subheadings. Demonstrate the ability to code Hemic and Lymphatic Systems services. Review the format of the Mediastinum and Diaphragm subsection codes. Understand the Mediastinum and Diaphragm information. Demonstrate the ability to code Mediastinum and Diaphragm services. CHATPER #23 Digestive System Week Nine Understand the format and codes of the Digestive System subsection. Report procedures of the lips. Report procedures of the vestibule of the mouth. Report procedures of the tongue and floor of the mouth. Report procedures of the dentoalveolar structures. Report procedures of the palate and uvula. Report procedures of the salivary gland and ducts. Report procedures of the pharynx, adenoids, and tonsils. Report procedures of the esophagus. Report procedures of the stomach. Report procedures of the intestines (except rectum). Report procedures of the Meckel s diverticulum and mesentery. Report procedures of the appendix. Report procedures of the rectum. Report procedures of the anus. Report procedures of the liver. Report procedures of the biliary tract. Report procedures of the pancreas. Report procedures of the abdomen, peritoneum, and omentum. CHAPTER #24 Urinary and Male Genital Systems Week Ten Understand the format and codes of the Urinary System subsection. Review the subheadings and categories of the Urinary System subsection. Report services with Urinary System codes. Understand the format and codes of the Male Genital System subsection. Review the subheadings and categories of the Male Genital System subsection. Report services with Male Genital System codes. CHAPTER #25 Reproductive, Intersex Surgery, Female Genital System, Week Eleven and Maternity Care and Delivery Describe reproductive services. Report reproductive services. 5

6 Report intersex surgery services. Understand the format of the Female Genital System subsection. Identify elements of component coding with Female Genital System codes. Define the critical terms in maternity and delivery services. Define services in the global maternity and delivery package. Understand the format of Maternity Care and Delivery subsection services. Demonstrate the ability to code Female Genital and Maternity Care and Delivery subsection. Examine the ICD-10-PCS System. CHAPTER #26 Endocrine and Nervous Systems Week Twelve Review the Endocrine System subsection format. Understand the Endocrine System subheadings. Demonstrate the ability to code Endocrine System services. Review the Nervous System subsection format. Understand the Nervous System subheadings. Demonstrate the ability to code Nervous System services. CHAPTER # 27 Eye, Ocular Adnexa, Auditory, and Operating Microscope Week Twelve Review the Eye and Ocular Adnexa subsection format. Understand the Eye and Ocular Adnexa subheadings. Demonstrate the ability to code Eye and Ocular Adnexa services. Review the Auditory System subsection format. Understand the Auditory System subheadings. Demonstrate the ability to code Auditory System services. Review reporting use of an operating microscope. Demonstrate the ability to report the use of an operating microscope. CHAPTER # 28 Radiology Week Thirteen Demonstrate an understanding of Radiology terminology. Analyze the elements of component coding in the reporting of radiology services. Identify the elements of the global procedure. State the appropriate coding of contrast material. Explain the format of the Radiology section. Demonstrate the ability to code Radiology services and procedures. CHAPTER #29 Pathology/Laboratory Week Fourteen Explain the format of the Pathology and Laboratory section. Understand the information in the Pathology and Laboratory Guidelines. Demonstrate an understanding of Pathology and Laboratory terminology. 6

7 Differentiate amongst the Organ or Disease Oriented Panels codes. Recognize Drug Testing codes. Identify Therapeutic Drug Assays codes. Classify Evocative/Suppression Testing codes. Explain Consultations (Clinical Pathology) codes. Interpret Urinalysis, Molecular Pathology Procedures, and Chemistry codes. Evaluate Hematology and Coagulation codes. Describe Immunology codes. Discriminate amongst Transfusion Medicine codes. Interpret Microbiology codes. Evaluate Anatomic Pathology codes. Summarize Cytopathology and Cytogenic Studies codes. Explain Surgical Pathology codes. Choose Other Procedures codes. Demonstrate the ability to code Pathology and Laboratory services. CHAPTER #30 Medicine Week Fifteen Analyze the format of the Medicine section. Report psychiatric services. Identify biofeedback services. List components of dialysis reporting. Demonstrate ability to report gastrointestinal services. Understand ophthalmology and otorhinolaryngologic reporting. Report cardiovascular services. Identify services reported with pulmonary codes. List the important elements of coding allergy and clinical immunology services. Report endocrine services. Define neurology and neuromuscular services. Demonstrate an understanding of central nerves assessment and intervention. Analyze chemotherapy services. Report special services and dermatologic procedures. Code physical medicine and rehabilitation services. Report active wound management. Define osteopathic and chiropractic services. Understand non-face-to-face services. Code special services, procedures, and reports. Report medical services using Medicine section codes. COURSE EVALUATION Class will focus on online lecture-discussion, structured group activities; reports may be assigned and other activities that will enhance the learning process. Students are evaluated on performance on online test scores and online assignments. 7

8 TESTS, ASSIGNMENTS AND GRADING POLICY Tests are given on each chapter. Tests will be delivered and submitted online. Tests will open and close on set dates. Please refer to course online site for additional information. Completed student workbooks are also required for each chapter. Workbook information will be submitted through the course site. All points for quizzes, midterm/final exams and assignments will be totaled and must average out to 74% or better to obtain a passing grade for this class. If 74% is not obtained, the student will need to repeat the class before moving to the next semester classes % A 74-76% C PASSING 90-94% A % C % B % D % B 64-66% D 80-83% B % D % C+ 0-59% E Tests are worth 100 points, students workbook chapters are worth 20 points, for a total of 360 points for all chapters. COURSE SCHEDULE Student workbooks are due the day of the theory test. The theory test will be given at the end of the chapter lecture, discussion and assignment. Please refer to online course site for course calendar. This calendar is subject to change. COURSE COMMUNICATION: 1. s will be sent through the course site. Check your often. 2. If you have questions, the instructor, using the course site. 3. Due dates for each quiz are posted on the course calendar. Chapter quizzes will be opened and closed at different times during the semester. Check the calendar and for the closing dates. Once a chapter quiz has been closed it will not be re-opened. GENERAL DISTANCE LEARNING INFORMATION: SLCC Online Support Centers Jordan HTC115; The SLCC Online Support Centers assist students in online classes with orientations, contacting instructors, faxing or mailing assignments and locating course websites. See the website for tips and orientation to online courses. To update your browser and other information about distance learning contact SLCC help desk at STUDENT CODE OF CONDUCT: The student is expected to follow the SLCC Student Code of Conduct found at Code of conduct violations are taken very seriously. Please consult with the OTA Student Handbook for details. 8

9 ADA STATEMENT: Students with medical, psychological, learning or other disabilities desiring accommodations or services under ADA must contact the Disability Resource Center (DRC). The DRC determines eligibility for and authorizes the provision of these accommodations and services for the college. Please contact the DRC at the Student Center, Suite 244, Redwood Campus, 4600 So. Redwood Road, Phone: (801) , TTY: , Fax: SALT LAKE COMMUNITY COLLEGE STATEMENT Salt Lake Community College is committed to fostering and assessing the following student learning outcomes in its programs and courses: Student Learning Outcomes Upon successful completion of any program at SLCC, students: 1. Acquire substantive knowledge in the discipline of their choice sufficient for further study, and/or demonstrate competencies required by employers to be hired and succeed in the workplace. 2. Communicate effectively. A. Develop critical literacies reading, writing, speaking, and listening that they can apply in various contexts. B. Organize and present ideas and information orally and in writing according to standard usage. C. Understand and use the elements of effective communication in interpersonal, small group, and mass settings. D. Gather and analyze information and communicate effectively using technology, library resources, and other media. 3. Develop quantitative literacies necessary for their chosen field of study. A. Approach practical problems by choosing and applying appropriate mathematical techniques. B. Use and interpret information represented as data, graphs, tables, and schematics in a variety of disciplines. C. Apply mathematical theory, concepts and methods of inquiry appropriate to program-specific problems. 4. Think Critically. A. Reason effectively using available evidence, and are aware that knowledge is dynamic and builds on new evidence and alternative perspectives. B. Demonstrate effective problem solving. C. Engage in creative thinking, expression, and application. D. Engage in reflective thinking and expression. E. Demonstrate higher-order skills such as analysis, synthesis, and evaluation. F. Make connections across disciplines. G. Apply scientific methods to the inquiry process. 5. Develop the knowledge and skills to be civically engaged, and/or to work with others in a professional and constructive manner. A. Understand the natural, political, historical, social and economic underpinnings of the local, national, and global communities to which they belong. B. Develop the awareness of both civil rights and civil responsibilities for individual and collective 9

10 action in a democracy. C. Engage in service-learning for community building and an enhanced academic experience. D. Develop the awareness and skills to take leadership roles in classrooms, the broader college, and the community. E. Engage in principled and vigorous dialogue. F. Interact competently across cultures. G. Understand and appreciate human differences. H. Understand and act on standards of professionalism and civility, including the requirements of the SLCC Student Code. Draft Calendar Date Topic Assignment Jan 14 Open and review of course Unit 1-Chapter 13 Module 13.1 Module 13.2 Module 13.3 Quiz #1 Jan 21 Jan 28 Module 13.4 Unit 2-Chapter 14 and 15 Module 14.1 Module 14.2 Unit 3-Chapter 15 Module 15.1 Module 15.2 Unit 3-Chapter 15 only Module 15.3 Module 15.4 Module 15.5 Feb 4 Unit 4-Chapter 16 and 17 Module 16.1 Module 16.2 Module 17.1 Feb 11 Feb 18 Feb 25 Mar 4 Mar 11 Mar 18 Unit 4-Chapter 18 Module 18.1 Module 18.2 Module 18.3 Unit 4-Chapter 19 Module 19.1 Module 19.2 Unit 4-Chapter 20 Module 20.1 Module 20.2 Unit 4-Chapter 21 and 22 Module 21.1 Module 21.2 Module 21.3 Module 22.1 Module 22.2 Spring Break Unit 4-Chapter 23 Module 23.1 Quiz #2 (14 Only) Quiz #3 (15 Only) Quiz #4 (Both) Quiz #5 Quiz #6 Quiz #7 Quiz #8 (Both) Spring Break Quiz #9 10

11 Mar 25 Module 23.2 Unit 4-Chapter 24 Module 24.1 Module 24.2 Apr 1 Unit 4-Chapter 25 Module 25.1 Module 25.2 Apr 8 Unit 4-Chapter 26 and 27 Module 26.1 Module 26.2 Module 27.1 Module 27.2 Apr 15 Apr 22 Apr 29 May 6 Midterm Exam (13-21) Quiz #10 Quiz #11 Quiz #12 (Both) Unit 4-Chapter 28 Quiz #13 Module 28.1 Module 28.2 Module 28.3 Unit 4-Chapter 29 Quiz #14 Module 29.1 Module 29.2 Unit 4-Chapter 30 Quiz #15 Module 30.1 Module 30.2 Module 30.3 Final Exam Final Exam (22-30) 11

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