Syllabus HIM 180 Credit Hours 4 Health Information Financial Management and Reimbursement Methods

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1 Syllabus HIM 180 Credit Hours 4 Health Information Financial Management and Reimbursement Methods DEPARTMENT: School of Health Sciences COURSE DESCRIPTION This required course will focus on financial concepts for healthcare managers, reimbursement methodologies and revenue cycle management. Readings will highlight the financing and delivery of health services in the United States. Emphasis is placed on case study and problem solving. Students must have completed at least two coding courses in order to be able to assimilate the revenue cycle management theories that are the focus of this course. Prerequisite: HIM 160, HIM 130 REQUIRED TEXTBOOKS Revenue Cycle Management Best Practices Nadinia Davis ISBN AHIMA Press Health Information Management Technology: An Applied Approach, 4th Edition, Nanette Sayles ISBN AHIMA Press HIT Page 1

2 AHIMA Body of Knowledge online articles COURSE OBJECTIVES Upon completion of this course, the health information technology student will be able to: Make recommendations for items to include in budgets and contracts. Define key terms associated with the healthcare financial environment. Recommend cost savings and efficient means of achieving work processes and goals Complete accurate and appropriate revenue bill reconciliation processes Identify national regulations for coding and billing compliance (i.e. NCCI) Use spreadsheets, graphics, and presentation applications to communicate financial and management concepts Assess reliability and validity of data used in Medicare/Medicaid billing Participate in the Clinical Documentation Improvement process Determine revenue impact of denied claims and fraud/abuse Create and Maintain a Charge Description Master STUDENTS WITH DISABILITIES: Students with documented disabilities (physical, emotional, learning and/or others) who believe that they may need accommodations in this class are encouraged to contact the Coordinator for Student Disability Services in Room 139, extension 120, as soon as possible to arrange for such accommodations. LIBRARY INFORMATION: Articles: As an MWCC student, you have access 24 hours a day to more than 80 LaChance Library online article databases. To get to these resources and find articles scholarly/academic journals, magazines, newspapers, reference books, and e-books, visit the Library web page, and click FIND ARTICLES. In order to access the Library s online research databases from an off-campus location, you will be prompted to log-in with your library barcode number or student ID number and last name in all CAPITAL LETTERS. Books, Videos, CDs, etc.: In order to find books, videos, etc. on a topic, you will need to use the Library catalog, located on the Library s webpage ( Look for the FIND BOOKS & MORE link. You may arrange to pick up items at either the LaChance Library or your public library. For assistance in locating articles, books or other information sources please contact us: By telephone: (toll free) Via library@mwcc.mass.edu (account is checked at least once daily at 7:30 am, Mon-Fri) Using chat: Visit the ASK A LIBRARIAN page at: In person, at the LaChance Library (Gardner Campus), Leominster Student Success Center and the Devens Learning Center when open. Hours can be found at: ACADEMIC SUPPORT CENTER INFORMATION: 2

3 Tutoring: Students in need of tutorial services are encouraged to contact the Academic Support Center. Tutorial services are provided free of charge to enrolled students and include face-to-face and e-tutoring (online tutoring), drop in help with math and writing, subject tutoring (sciences, business, accounting, etc.) as well as other services. If you have questions, or wish to set up an appointment, you may contact: Administrative Assistant, Academic Support Center, ETutoring is available to students through iconnect and provides tutoring in subjects such as writing, math, biology, chemistry, anatomy & physiology, statistics and accounting. Assistance is available via chat, and also an online writing lab where students can upload drafts of papers and receive feedback. To see the current schedule of etutoring visit: For information about either library or tutoring services please contact Heidi McCann, Dean of Library and Academic Support Services or ACADEMIC HONESTY & PLAGIARISM: Students are responsible for knowing Mount Wachusett Community Colleges' policy on academic honesty and plagiarism, found at In sum, it is against policy to submit work with the deliberate intent to deceive or to cheat. Plagiarism is not tolerated at the College. WITHDRAWAL FROM A COURSE: You may formally withdraw from this course through the 60% point of the semester/cycle as indicated on the academic calendar the academic calendar is posted at A grade of W will be recorded on your transcript. A grade of W will count as credits attempted but not completed, but will not impact QPA. You are required to speak to me or your assigned advisor before withdrawing from this course. The procedure for course withdrawal includes getting the proper form from the Advising Center in Gardner or from the receptionist at our branch campuses (Leominster, Devens, Burbank), bringing the form to me or your assigned advisor, and returning the signed form to the Advising Center or branch campus. Please be advised that ceasing to attend a class may result in me initiating the withdrawal from a class prior to the 60% point of the semester/cycle. Course withdrawals will not be processed after the 60% point of the semester/cycle. If you stop attending after the 60% point of the semester/cycle, you will receive an F grade. F s are averaged into the QPA for all students. Any withdrawal may affect progress toward degree and future eligibility to receive financial aid. Contact the record s office for information on your student records. Administrative action Forms are available for withdrawal after the 60% point of the semester/cycle as a result of extenuating circumstances. Student may obtain an Administrative Action form in the records office or online at 3

4 content/blogs.dir/1/files/2013/01/administrative-action.pdf. Documentation of the extenuating circumstance must be submitted with the form for this appeal to be reviewed. PERFORMANCE ASSESSMENT This course is designed to complement the AHIMA National Model Curriculum Map for HIT programs. The following Domains, Subdomains and Task competencies are addressed in this course. With a minimum accuracy of 76%, the student must demonstrate acceptable performance via lab exercises, assignments, quizzes and exams. AHIMA Academic Domains/Sub domains The following Domains, Subdomains, and Task Competencies of the health information technology profession are addressed in this course. The material in this course is consistent with the following AHIMA Curriculum Competencies that are in effect as of Fall 2011: Domain 1: Health Data Management Subdomain 1.a: Health Data Structure, Content, and Standards Task 1.a.4: Verify timeliness, completeness, accuracy, and appropriateness of data and data sources for patient care, management, billing reports, registries, and/or databases. Subdomain 1.b: Healthcare Information Requirements and Standards Task 1.b.2: Apply policies and procedures to ensure organizational compliance with regulations and standards. Domain 4: Information Technology & Systems Subdomain 4.a: Information and Communication Technologies Task 4.a.2: Use common software applications such as spreadsheets, databases, word processing, graphics, presentation, , and so on in the execution of work processes. Domain 1: Health Data Management Subdomain 1.d Reimbursement Methodologies Apply policies and procedures for the use of clinical data required in reimbursement and prospective payment systems (PPS) in healthcare delivery. Apply policies and procedures to comply with the changing regulations among various 4

5 payment systems for healthcare services such as Medicare, Medicaid, managed care, and so forth. Support accurate billing through coding, charge master, claims management, and bill reconciliation processes. Use established guidelines to comply with reimbursement and reporting requirements such as the National Correct Coding Initiative. Compile patient data and perform data quality reviews to validate code assignment and compliance with reporting requirements, such as outpatient prospective payment systems. Ensure accuracy of diagnostic/procedural groupings such as DRG, APC, and so on. Subdomain 5 b: Financial and Resource Management Make recommendations for items to include in budgets and contracts. Monitor coding & revenue cycle processes. This course additionally covers the following RHIT Exam Blueprint Competencies: DOMAIN VII Revenue Cycle (11% of the exam) 1. Communicate with providers to discuss documentation deficiencies (i.e. queries) 2. Participate in clinical documentation improvement programs to ensure proper documentation of health records 3. Collaborate with other departments on monitoring accounts receivable (i.e. unbilled, uncoded) 4. Provide ongoing education to healthcare providers (i.e. regulatory changes, new guidelines, payment standards, best practices, etc.) 5. Identify fraud and abuse 6. Assist with appeal letters in response to claim denials 7. Monitor claim denials/over-payments to identify potential revenue impact 8. Prioritize the work according to accounts receivable, patient type, etc. 9. Distribute the work according to accounts receivable, patient type, etc. 10. Maintain the charge master (CDM) COURSE REQUIREMENTS A. Completion of all readings, labs, assignments, and homework in a timely manner B. Actively participate in class discussion and simulations per institution policy C. Pass exams and quizzes EVALUATION Course grade will be determined as follows: Course grade will be determined as follows: A. Assignments 70% B. Discussion Boards 30% Grading Scale: The college uses the following grading system: 5

6 Letter Quality Grade Points A 4.00 A B B 3.00 B C C 2.00 C D D 1.00 D F 0.00 Active Engagement Rubric Each week, the class will focus on a given topic to discuss and investigate. Students will participate either through in-class debates, or by posting discussions in the learning management system. Possible grade is between 100 and 0. Below is an example of how student gets from F to A on active participation/course discussion Grade 100 points 80 points 60 points Organization Comments are well organized and reflect student has read materials Comments can be followed, but may be based on experience or reflects responding to others Comments/participation/ is disorganized or sporadic Quality of Information Comments demonstrate student understands the topic information. New information or insights are offered. Comments show student is trying to relate topic to weekly readings. Comments drift from topic, tend to be generic and add little or no value to the dialogue. Sources Comments are supported by one or more referenced citations - supports ideas with facts/quotes May use a citation, or makes reference to personal work experience to support an idea Makes a post but it is unsupported by citation or experience, and is very brief. 6

7 Participation Student participates four or more times during the discussion period Student participates at least twice with an original comment and at least one reply/reaction to another student. Student comments or posts once. Non-participation = 0 HIT 150 Lecture Topics HIT 180 Course Outline (15 Modules) HIT 180 Readings & Slides HIT 180 Lab MODULE 1: Revenue Cycle Basics - Overview of the Revenue Cycle - Charge Capture/Billing - Medicare Payment Systems - Establishing Benchmarks - Analysis and Measurement Topic of the Week: Select one of the 10 key revenue cycle performance measures and learn more about it on the web (Fig 1.1). MODULE 2: Revenue Cycle Basics (con t) - Quality Assurance - PDCS, Six Sigma - Lean Methodologies - Workflow Assessments in various settings Topic of the Week: Visit a website to learn more about Six Sigma and share something interesting that you didn t know about this process. MODULE 3: Cost Analysis and Payer Contracts - Cash flow issues - Cost to provide service - Fraud and Abuse - Vendor Contracts - Financial Obligations Topic of the Week: A very successful CEO of a nonprofit hospital said No profit = no mission in your own words, explain what this quote means. Read Davis CH 1 pp 1-15 Read Davis CH 1 pp Read Davis CH 2 pp Install the CD ROM found in the back of the book, a variety of forms on the CD will be used in the course. Complete Quality Guidelines Assignment Complete Lean Methodologies Assignment Complete What Everyone Should Know About Negotiating Contracts Assignment 7

8 MODULE 4: Cost Analysis and Payer Contracts - Determining costs - HIM Cost Accounting - Chrage Description Master - Medicare Cost Report - Determining Charges - Practice Settings Read Davis CH 2 pp Review: Appendix 2.1, 2.2, 2.3 Forms HO The Why of CDMs Complete PPS Assignment Complete Comparison of PPS Assignment Topic of the Week: Appendix 2.1 shows a sample of a job notice for a HIM Compliance Specialist. Visit a job search engine and compare an actual current Compliance specialist position against this form what are the differences? MODULE 5: Patient Access - Patient Identification Management - Dups, Overlays, MPI Cleanup - Data Integrity Read Davis CH 3 pp HO Patient Disposition Complete Discharge Disposition Assignment Topic of the Week: Search the web and see if you can find a software vendor that specializes in this type of work. MODULE 6: Patient Access Read Davis CH 3 pp Financial data and accuracy - Payment options - Government payers - special considerations for practice settings Complete Medicare/Medicaid Assignment Topic of the Week: What are the Red Flag Rules? Give an example. MODULE 7: Documentation and Charge Capture - Account Types - CDI Programs - Charge Master Maintenance - Bundling Issues Topic of the Week :Appendix 3.1 shows the exam outlines for two certifications: CHAM and CHAA. Find out more about these certifications and share what you learn. Read Davis CH 4 pp HO Chargemaster Creation Example Complete CDM Basics Assignment 8

9 MODULE 8: Documentation and Charge Capture - Internal Controls - Reconciling Orders - Special Considerations for Practice Settings Read Davis CH 4 pp Complete Data Quality Graph Assignment Topic of the Week: Pg 117 shows a startling example of the difference between what a doctor documents (anemia) and what the coder needs to try and discover. Find another example of a vague disorder/disease and compare the coding choices. MODULE 9: Record Completion & Coding - Backlogs and Incomplete Records - Creating Clean Claims - Monitoring Coding Accuracy Read Davis CH 4 pp Complete Preventive Controls Assignment Topic of the Week In your own words, what s the biggest difference between CDM coding and chart coding? Module 10 How Charges Become Revenue - Sources of financial data - Reading Financial Statements - Interpret Financial Statement Fig A.2 Read Davis Appendix A HO Charge Entry Flowchart Complete Interpreting Financial Statement Assignment MODULE 11: Record Completion & Coding - POA Present on Admission - CMI in MS-DRGs - Regulatory Requirements - RAC audits - Special Considerations for Practice Settings Read Davis CH 4 pp Complete RAC Inservice Assignment MODULE 12 Claims Management - Clean Claims in electronic billing - Contract management - Use of Edits Read Davis CH 5 pp Complete Low Tech Claims Assignment Module 13 Claims Management - Denial Management - Causes for Bill Hold/Delays - RAC Audits - Collections -- Special Considerations for Practice Settings Read Davis CH 5 pp Complete Building ICD10 into CDM Assignment 9

10 Module 14 Patient Identity & Interdepartmental Relations - Patient Identity - Patient Registration - Billing Department - Patient Care Departments - Information Systems - Quality Management Topic of the Week: Medical Patient Identity Theft is a new and growing phenomena. Investigate the web and find a case involving medical identity theft (fraud). Read Sayles CH 7 pp Read Sayles CH 7 pp View Video Patient Identity Theft ch?v=y3apb5afdks Complete the Check Your Understanding questions found on pp Complete the NEEHR PERFECT MPI Scavenger Hunt assignment Module 15 Future Directions of HIM & Technology - ONC Training Programs - Shift to ICD-10 - New regulations on privacy and security Read Sayles CH 7 pp Complete the Check Your Understanding 7.8 questions found on pp Topic of the Week Visit the ONC website and review the various types of certificates available for training what roles/certificates are offered, and which interests you? Finals Week Course Evaluation Complete Final Report 10