Course Syllabus. COURSE IDENTIFICATION Course Prefix/Number: ALHT 230

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1 Course Syllabus COURSE IDENTIFICATION Course Prefix/Number: ALHT 230 Course Title: Division: Outreach and Workforce Development Program: Health Information Technology Credit Hours: 3.0 Initiation/Revised Date: Assessment Goal per Outcome(s): 80% Instructor Jean Ann Jones, RHIT, CPC Contact Information: CLASSIFICATION OF INSTRUCTION Vocational COURSE DESCRIPTION This course prepares students for entry level positions in a physician s office or other medical facility. The focus of this class is learning the coding rules for the Current Procedural Terminology (CPT), and Level I (HCPCS) coding systems and then applying the rules to code patient services. Students will need CPT and HCPCS Level II manuals for the course. PREREQUISITIES AND/OR COREQUISITES: None REQUIRED TEXTBOOKS: *The official list of textbooks and materials for this course are found on Inside NC. Step by Step Medical Coding, Current Edition, By: Carol J Buck, Saunders: ISBN: CPT - Current Procedural Terminology Professional Edition. American Medical Association, Current year edition: ISBN: HCPCS Level I, Medicare, American Medical Association Current year edition. OTHER RESOURCES: Flashcode/AHIMA Virtual Lab-Quantim: Review Tabular List for fourth or fifth digits. Use Flashcode to verify correct code. Use Virtual Lab's Quantim Code to verify codes (can verify procedure codes with Quantim Code). Also use these systems to review the Tabular List for includes, excludes, and code also guides. These systems also provide references: Coding Clinics, medical dictionary, drug index, anatomy, clinical indicators, lab values, abbreviations, and ICD-9 guidelines. AHIMA s Virtual Lab: American Health Information Management Association

2 Chapman Library Online Database, Magazine/Journals, ProQuest Nursing & Allied Health (see Campus Announcements on Home Page of Inside NC for instructions and access). COURSE OUTCOMES/COMPETENCIES (as Required) Outcome I: Demonstrate an understanding of CPT coding manual in order to assign valid procedure codes. A. Identify the purpose of the CPT manual and setting where use of CPT is required. B. Identify placement of CPT codes on CMS-1500 insurance form. C. Recognize the symbols used in the CPT manual. D. List the major sections found in the CPT manual. E. Interpret information in section Guidelines and notes. F. Apply and define purpose of modifier in code assignment. G. Determine what is meant by unlisted procedure/services. H. State the purpose and contents of a special report. I. List methods used to locate terms and codes in the CPT manual. J. Identify content of CPT appendices. Outcome II: A. Delineate the three factors of E/M code assignment. B. Analyze the differences among new, established, inpatient, and outpatient. C. Explain the levels of E/M service. D. Analyze the key component and contributing factors. E. Identify critical elements of Documentation Guidelines. F. Assign E/M codes to services and procedures and use appropriate modifiers. Outcome III: Demonstrate an understanding of coding and classification systems in order to assign valid CPT procedure codes (Anesthesia codes ). A. Describe the anesthesia section and its codes. B. Incorporate the physical status modifiers and their use with anesthesia codes. C. List services included in the anesthesia code package. D. Discuss other anesthesia coding systems and their use by physicians. E. Assign Anesthesia codes to services and procedures. Outcome IV: Demonstrate an understanding of coding and classification systems in order to assign valid CPT procedure codes (Surgery/Integumentary/Musculoskeletal/Respiratory/Cardiology/ Digestive/ Urinary/Male and Female Genital/Nervous/Eye and Ocular codes ).

3 A. Describe the format and basic contents of the surgery section of the CPT codebook and its subsections. B. Define the surgical package and the services included in it. C. Describe the coding conventions specific to each surgery subsection. D. Define terminology used in each surgery section and subsection. E. Understand the National Correct Coding Initiative and determining when a procedure is a component of a larger procedure with the use of and encoder. F. Assign codes that apply to each surgery subsection. Outcome V: Demonstrate an understanding of coding and classification systems in order to assign valid CPT procedure codes (Radiology codes ) A. Describe the structure of the radiology section. B. Discuss the concept of radiological supervision, compared to interpretation only, as it is used with radiology. C. Identify modifiers used in the radiology section. D. Understand the different types of radiology services (Diagnostic, Interventional, Radiation Oncology, Nuclear Medicine). E. Assign Radiology codes to services and procedures. Outcome VI: Demonstrate an understanding of coding and classification systems in order to assign valid CPT procedure codes (Pathology and Laboratory codes ). A. Describe method used to locate pathology and laboratory codes in the CPT book. B. Distinguish between quantitative and qualitative: in relation to pathology and lab codes. C. Identify modifiers commonly used in the pathology/laboratory section. D. Assign appropriate codes for pathology and laboratory services/procedures. Outcome VII: Demonstrate an understanding of coding and classification systems in order to assign valid CPT procedure codes (Medicine Codes , ). A. Describe the medicine section and its codes. B. Identify conventions specific to the immunization injections. C. Discuss the use of hydration, therapeutic, prophylactic, and diagnostic injections and infusions. D. Demonstrate understanding of the various specialty procedures. E. Explain the reporting of chemotherapy administration. F. Assign Medicine codes to services and procedures.

4 Outcome VIII: Demonstrate an understanding of coding and classification systems in order to assign valid HCPCS Level II procedure codes A. Describe general guidelines for HCPCS Level II coding. B. Manage HCPCS modifiers. Outcome IX: Demonstrate an understanding of Third Party Reimbursement Issues A. Identify the basic components of the outpatient code editor. B. Explain the inpatient prospective payment system (IPPS), the MS-DRG/DRG and understand the grouper of the ICD-9. C. Recognize and understand the outpatient Resource-Based Relative Value Scale (RBRVS), Ambulatory Payments System (APC), and Prospective Payment System for the Skilled Nursing Facility (RUG III). D. Explain the purpose of the Quality Improvement Organization E. Discuss Medicare Fraud and Abuse F. Identify major components of the Managed Health Care AHIMA DOMAINS Domain 1: Health Data Management. Subdomain A: Health Data Structure, Content and Standards 4. Apply clinical vocabularies and terminologies used in the organization s health information systems. Subdomain C: Clinical Classification Systems 1. Use and monitor applications and work processes to support clinical classification and coding 2. Apply diagnosis/procedure codes using ICD-9-CM 3. Apply procedure codes using CPT/HCPCS 4. Ensure accuracy of diagnostic/procedural groupings such as DRG, APC, and so on. 5. Adhere to current regulations and established guidelines in code assignment. 6. Validate coding accuracy using clinical information found in the health record 8. Resolve discrepancies between coding data and supporting documentation Subdomain D: Reimbursement Methodologies 1. Apply policies and procedures for the use of clinical data required in reimbursement and prospective payment systems (PPS) in healthcare delivery 3. Use established guidelines to comply with reimbursement and reporting requirements (e.g., National Correct coding Initiative [NCCI]; Local Medical Review Policies[LMRP]) 4. Compile patient date and perform data quality reviews to validate code assignment and compliance with reporting requirements such as outpatient prospective payment systems. Domain 2: Health Statistics, Biomedical Research and Quality Management

5 Subdomain A: healthcare Statistics and Research 1. Abstract and maintain data for clinical indices/databases/registries Domain 3: Health Services Organization and Delivery Subdomain A: Healthcare Delivery Systems 3. Apply policies and procedures to comply with the changing regulations among various payment systems for healthcare services such as Centers for Medicare and Medicaid Services (CMS), managed care Domain 4: Information Technology Systems Subdomain A: Information and Communication Technologies 2: Use specialized software in the completion of HIM processes (e.g.,coding) Domain 5: Organizational Resources Subdomain B: Financial and Physical Resources 3. Monitor coding and revenue cycle processes COURSE OUTLINE I. Current Procedural Terminology (CPT). A. Introduction to the CPT B. Evaluation and Management C. Anesthesia Section and Modifiers D. Intro to the Surgery Section and Integumentary System E. Musculoskeletal System F. Respiratory System G. Cardiovascular System H. Female Genital and Maternity Care and Delivery I. General Surgery J. Radiology Section K. Pathology/Laboratory Section L. Medicine Section and Level II National Codes M. Overview of the ICD-9-CM N. Using ICD-9-CM O. Third Party Reimbursement Issues SCHEDULE This class meets online for weekly learning units. The class materials for each unit will be available for a minimum of eight days, starting and ending. Week Topic/Exam Readings/Activities 1 Class Introductions, Completion of *This course will make extensive use necessary forms. Coding ethics. of the electronic systems: Flashcode and AHIMA s Virtual Lab-Quantim. *Post introduction on the collaboration website. Read the information provided regarding coding ethics from the AHIMA website.

6 Introduction to the CPT *Chapter 1 * Review Questions at the end of the Chapter; submit answers to instructor via . Evaluation and Management Services Modifiers *Read Chapter 2 *Complete Review Questions at the end of the Chapter. (Turn in answers via to instructor) *Test over Chapter 1 Anesthesia Section and Modifiers *Read Chapter 3. *Complete Review Questions at end of the Chapter. (Turn in answers via to instructor) *Test over Chapter 2 Introduction to Surgery and Integumentary System Musculoskeletal System Respiratory System Cardiovascular System Male and Female Genital System Endocrine, Nervous System, Eye, and Auditory System *Read Chapter 4 pages *Complete Exercise (Turn in answers via to instructor) * Complete Additional Practice Exercises assigned by instructor and turn in answers via to instructor *Test over Chapter 3 *Read Chapter 5 and 6 end of Chapter (Turn in answers via to instructor) *Complete Flash Code Assignment, Introduction to the software * Test over Chapter 4 *Read Chapter 7 Complete Review Exercises at end of Chapter and use Flash Code Software for the CPT coding answers. (Turn in answers via to instructor) * Complete Library assignment on cardiac information *Test over Chapter 5 and 6 *Read Chapter 8 end of Chapter using Flash Code software with the CPT coding and turn in answers via to instructor

7 Test Chapter 8 Mid-Term Exam *Library Assignment over High Risk Pregnancy *Test over Chapter 7 * Exam Chapter 8 * Mid-Term Exam General Surgery *Read Chapters 9 & 10 end of chapter. (Turn in answers via to instructor) *Introduction to AHIMAVirtual Lab for the Quantim *Test over Chapter 8 Radiology Pathology/Laboratory Services *Read Chapter 11 & 12 *Complete Review Exercise at end of the chapter. (Turn in answers to instructor via ) *Complete the use of Virtual Lab with the radiology and lab coding *Test over Chapter 9 & Medicine Section and HCPCS Level II *Read Chapter 13 end of each chapter. (Turn in answers via to instructor) *Complete Additional Practice Exercises assigned by instructor and sent to instructor via . *Test Chapter 11 & Overview of the ICD-9-DM *Read Chapters 14 end of chapter. (Turn in answers via to instructor) *Complete Additional Practice Exercises assigned by instructor and sent to instructor via Using the ICD-9-CM Overview of ICD-10-CM 15 Third Party Reimbursement Issues Read Chapters 15 end of the chapters. *Complete Additional Practice Exercises assigned by instructor and turn in answers via to instructor *Test Chapter 14 *Read Chapter 16 *Complete Review exercises at end of Chapter (Turn in answers

8 via to instructor). *Test over Chapter 15 *Test over Chapter Final Final Exam INSTRUCTIONAL METHODS The instructional methods used include internet lecture, CD Activities, workbook completion, group assignments, and collaborative projects. Students will be required to complete reading assignments, chapter reviews, case studies, participate in threaded discussions with other classmates on topics determined by instructor, complete assignments and examinations of knowledge, and demonstrate skill competency using a specific internet platform. Students must participate in all activities, as well as accurately complete assignments and examinations within the internet platform in a timely manner. Therefore it is imperative that students have a reliable internet provider, computer hardware, and address to succeed in this course. STUDENT REQUIREMENTS AND METHOD OF EVALUATION Evaluation is directly related to the performance objectives. Performance is measured by examination, assignments, and/or quizzes. GRADE SCALE The letter grade is based on the percentage of the total weighted points earned throughout the semester based on the following scale: A = 90 to 100% B = 80 to 89% C = 70 to 79% D = 60 to 69% F = 59% and below Assignments 85 % Students will be required to complete weekly assignments. Each assignment will be worth a minimum of 10 and a maximum total of 100 points. Midterm/Final Examination 15% Students will take comprehensive midterm and final examinations. The examination will be worth a maximum of 400 points. 282 pts. Questions/Assignments 386 pts. Exams Total Points Possible: 778

9 ASSESSMENT OF STUDENT GAIN Student gain will be determined by student improvement in each of the areas of student competencies. ATTENDANCE POLICY Absences that occur due to students participating in official college activities are excused except in those cases where outside bodies, such as the State Board of Nursing, have requirements for minimum class minutes for each student. Students who are excused will be given reasonable opportunity to make up any missed work or receive substitute assignments from the instructor and should not be penalized for the absence. Proper procedure should be followed in notifying faculty in advance of the student s planned participation in the event. Ultimately it is the student s responsibility to notify the instructor in advance of the planned absence. Unless students are participating in a school activity or are excused by the instructor, they are expected to attend class. If a student s absences exceed one-hundred (100) minutes per credit hour for the course or, in the case of on-line or other non-traditional courses, the student is inactive for one-eighth of the total course duration, the instructor has the right, but is not required, to withdraw a student from the course. Once the student has been dropped for excessive absences, the registrar s office will send a letter to the student, stating that he or she has been dropped. A student may petition the chief academic officer for reinstatement by submitting a letter stating valid reasons for the absences within one week of the registrar s notification. If the student is reinstated into the class, the instructor and the registrar will be notified. NCCC ACCOUNT Students should set up their NCCC accounts (which is the only account NCCC uses for students). Below is the link to a detailed handout that shows how to set it up. ACADEMIC INTEGRITY NCCC expects every student to demonstrate ethical behavior with regard to academic pursuits. Academic integrity in coursework is a specific requirement. Definitions, examples, and possible consequences for violations of Academic Integrity, as well as the appeals process, can be found in the College Catalog, Student Handbook, and/or Code of Student Conduct and Discipline. This online class allows you to work independently or with other students in the class. For your own benefit, you need to complete all assignments on your own unless otherwise indicated. Do not use the work of others and submit it as your own. You may refer to the textbook and resources when taking tests online, however the tests are timed and you may lose points if you exceed the time limit. The true test of what you learn in this class will be demonstrated when you take the AHIMA certification exam to become a Registered Health Information Technician. The expectation for this class is for you to be professional and ethical do your own work.

10 Note: Information and statements in this document are subject to change at the discretion of NCCC. Changes will be published in writing and made available to students. NOTE: If you are a student with a disability who may need accommodation(s) under the Americans with Disabilities Act (ADA), please notify the Dean of Student Development, Chanute Campus, Student Union, , Ext. 213., or the Dean, Ottawa Campus, ext 312, as soon as possible. You will need to bring your documentation for review in order to determine reasonable accommodations, and then we can assist you in arranging any necessary accommodations. DISCLAIMER: This syllabus is a broad outline of subject matter intended to be covered. It does not mean that everything herein will be covered, nor does it limit the content of the class to the material described. Information and statements in this document are subject to change at the discretion of NCCC. Because is required for the completion of the HIT Program, a grade of C or better is required to continue the program.

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