CODING and CODING LABORATORY Health Information Technology Program. Course Number: John A. Logan College HIT 204 Shawnee Community College HIT 204

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1 CODING and CODING LABORATORY Health Information Technology Program Course Number: John A. Logan College HIT 204 Shawnee Community College HIT 204 Hours of Lecture: 4 Hours of Lab: 2 Total Credits: 5 Semester/Year: Fall, 2015 Prerequisite: Instructor: Texts: Fundamentals of Medical Science Anatomy & Physiology Chris Froemling, RHIA, CCS John A. Logan College 700 Logan College Road Carterville, IL Office C259G Office Phone: (618) , ext Leon-Chisen, Nelly, ICD-10-CM and ICD-10-PCS Coding Handbook Without Answers, 2015 Edition, ISBN Published by American Hospital Association ICD-10-CM Expert for Hospitals, 2015 Edition, Published by Optum ICD-10-PCS, 2015 Edition, Published by Optum Abdelhak, Mervat, Health Information: Management of a Strategic Resource, 4 th edition, ISBN Published by Elsevier/Saunders Lecture Date/Time: Monday & Wednesday 11:15 1:05 Laboratory: Wednesday 9:00-10:50 Location: E130 Course Description: A study of classifications and nomenclatures, with in-depth coverage of the International Classification of Diseases, 10 th Revision, Clinical Modification (ICD-10-CM) and the International Classification of Diseases, 10 th Revision, Procedure Classification System (ICD-10-PCS) coding systems. 1

2 Objectives: The following is a listing of course objectives which the student should achieve by the conclusion of the course. 1. Understand the specific ICD-9-CM, ICD-10-CM, and ICD-10-PCS conventions, rules, and principles required for accurate coding. 2. List, describe, and demonstrate the use of various nomenclatures and classification systems used in health care. 3. Integrate previously acquired knowledge in medical terminology, anatomy and physiology, and pathophysiology. 4. Read and interpret diagnostic and procedural statements and medical data. 5. Apply ICD-9-CM, ICD-10-CM, and ICD-10-PCS coding conventions, rules and principles to assign accurate codes. 6. Critically think through the step-by-step process of interpreting medical data and assigning correct ICD-9-CM, ICD-10-CM, and ICD-10-PCS codes. 7. Select the correct principal diagnosis and correctly sequence all other diagnoses following AHIMA and federal regulations. 8. Select the correct principal procedure (when applicable) and correctly sequence all other procedures. 9. Understand the Inpatient and Outpatient Prospective Payment Systems, validating and assigning the correct Diagnosis Related Group (DRG) or Ambulatory Payment Classification (APC) category for Medicare records utilizing an automated grouper. 10. Develop proficiency using the 3M Coding and Reimbursement and QuadraMed Quantim encoding and grouping software. 11. Validate coding accuracy using clinical information found in the medical record. 12. Demonstrate knowledge of HIPAA Coding Compliance Standards. 13. Analyze coding for data quality. 14. Recognize documentation requirements for each chart coded. 15. Demonstrate knowledge of case-mix analysis, indices, and data quality issues. Expected Course Behaviors, Attitudes, and Values: 1. Listen attentively during lecture and discussion in order to learn the fine details of ICD-9-CM, ICD-10-CM, and ICD-10-PCS coding. 2. Ask questions to clarify points of confusion. 3. Appreciate the detail and accuracy required to assign correct codes. 4. Read ahead and complete homework according to due dates. 5. Value practice time outside of class required to learn to accurately assign codes. 6. Realize the importance and universal use of different classification systems in health care. 7. Write code numbers accurately and legibly. Clearly differentiate letters and numbers of similar appearance. 8. MAINTAIN A POSITIVE ATTITUDE! 9. AGAIN, MAINTAIN A POSITIVE ATTITUE! 2

3 Exams: With the exception of Unit I, each test is broken down into two sections - a theory section and a coding section. (Unit I only has a theory portion.) Open books are not permitted during the theory portion of the exam. The coding books must be used for the coding portion of the exam. There is a two hour limit on each exam. Each exam can be taken a maximum of two times. Two parallel, but different, forms of each test are available. The two parallel forms of the test are A and B respectively. It is not mandatory to take the Form B test, however it is strongly encouraged. The higher of the two test results is recorded and the lower of the two test results is discarded. The theory and coding sections of the exam will not be separated. Form A theory will not be combined with Form B coding (or vice versa) in order to raise a student s grade. Students can utilize Form A to study for Form B during classroom time only. Copies will not be made and originals will be monitored closely. All tests are taken during the time indicated on the course outline unless prior approval is granted by the instructor. If a student misses either Form A or Form B, he/she will only have the one opportunity to test. If a student misses both Form A and B tests, he/she may make it up by taking one form of the exam. The exam grade will automatically be dropped one letter grade if prior arrangements are not made with the instructor. However, if prior notification is given, the exam may be taken early with no penalty. If a student needs to step out of the classroom to use the bathroom during a coding exam, he/she may do so as long as they quietly notify the instructor. Only one student may be out of the classroom at a time. The two hour timer does not stop while you are out of the room. Students will not be allowed to take their cellphones or other electronic devices out of the room during the exam. Homework: Homework assignments must be handed in or graded at the beginning of class. Assignments will not be accepted after the answers are provided in class. If the student is going to be absent, faxed or ed homework will be accepted if received prior to class. The failure to complete a homework assignment prior to the start of class results in zero (0) points for that assignment. If time allows, homework assignments will be graded during the class in which the assignment is due. Students need to have a highlighter and/or red pen to grade the homework assignments and make notes on the homework accordingly. Homework that has been graded in pencil or blue/black ink will not be accepted. Scoring for all tests, assignments, and case studies: Note The maximum number of points deducted will not be greater than the total worth of the question. 1. Work must be neat and legible. Five (5) points will be deducted for careless work. 2. One (1) point will be deducted for each incorrect code assigned. 3. One (1) point will be deducted if a code that should have been assigned is not listed. 4. One (1) point will be deducted if a code number is assigned when it should not have been assigned. 5. One (1) point will be deducted if the principal diagnosis is incorrectly sequenced. 6. One (1) point will be deducted if 0 appears as an O (or vice versa), if a Z appears as a 2 (or vice versa), or any similar situations appear. 3

4 Evaluation: Test, homework, and case study scores are weighted on the following scale: Unit Tests 70% Homework 15% Case Studies 15% Grading Scale: A B C D E/F 68 and below Progression in the HIT program requires that the student earn a grade of C or better in this course. Grades of D or E/F are considered failing. If a student fails this course, it must be repeated with a passing grade of A, B, or C in order to continue in the HIT program. Absenteeism Policy: Each student is expected to attend all class meetings. The student is expected to be on time and ready to begin class with the proper materials at the beginning of each class period. Arrivals after class has begun will be counted as present, but tardy. Three occurrences of tardiness will be counted as one absence. Students that have three absences will have their course grade dropped by one letter grade. Five absences will result in the student being dropped from the course. Student Support Services: Student support services are available at every college represented within the SICCM HIT program. Services are available for students with a disability for a wide variety of needs (i.e. tutors, note takers, interpreters, un-timed testing) and are described in the college catalogs and student handbooks. Information and referral may also be obtained from the HIT Program Director. Cell Phones: Cell phones are prohibited during classroom instruction or testing. If a student has a special circumstance that requires a cell phone to be on during class, the instructor must be notified and give prior approval. Students have breaks between classes to use their cell phones. Academic Integrity: This class is subject to the college s Academic Integrity policy. All submitted work must be your own. Cheating and plagiarism will not be tolerated. Any student found in violation of this policy will be subject to disciplinary action as outlined in the student handbook and campus Academic Integrity policy. Equal Educational Opportunity: The colleges are committed to providing equal educational opportunities for all persons without regard to race, color, religion, sex, age, national origin, or disability. 4

5 Coding & Coding Lab Course Outline Fall 2015 Coding Units Unit I Abdelhak Chapter 6, Handbook Chapters 1 11, Appendix B Unit II Handbook Chapters Unit III Handbook Chapters Unit IV Handbook Chapters Unit V Handbook Chapters Unit VI Handbook Chapters Date Wed. 8/19/15 Mon. 8/24/15 Wed. 8/26/15 Mon. 8/31/15 Wed. 9/2/15 Mon. 9/7/15 Wed. 9/9/15 Mon. 9/14/15 Wed. 9/16/15 Mon. 9/21/15 Information To Be Covered Introduction to course Lecture Unit I Questions regarding Unit I No class Labor Day Test Unit I, Form A Lecture Unit II Lecture Unit II continued Test Unit I, Form B Lecture Unit II continued Lecture Unit II continued Questions regarding Unit II 5

6 Wed. 9/23/15 Mon. 9/28/15 Wed. 9/30/15 Mon. 10/5/15 Wed. 10/7/15 Mon. 10/12/15 Wed. 10/14/15 Mon. 10/19/15 Wed. 10/21/15 Mon. 10/26/15 Wed. 10/28/15 Mon. 11/2/15 Wed. 11/4/15 Test Unit II, Form A Lecture Unit III Lecture Unit III continued Test Unit II, Form B Lecture Unit III continued Lecture Unit III continued Questions regarding Unit III Test Unit III, Form A Lecture Unit IV No class Fall Break Test Unit III, Form B Lecture Unit IV continued Lecture Unit IV continued Lecture Unit IV continued Questions regarding Unit IV Lecture Unit V Test Unit IV, Form A Test Unit IV, Form B Lecture Unit V continued Lecture Unit V continued Lecture Unit V continued Questions regarding Unit V Lecture Unit VI 6

7 Mon. 11/9/15 Wed. 11/11/15 Mon. 11/16/15 Wed. 11/18/15 Mon. 11/23/15 Wed. 11/25/15 Mon. 11/30/15 Wed. 12/2/15 Mon. 12/7/15 Wed. 12/9/15 Test Unit V, Form A No class Veteran s Day Lecture Unit VI continued Test Unit V, Form B Lecture Unit VI continued Lecture Unit VI continued Questions regarding Unit VI No class Thanksgiving break Test Unit VI, Form A Lecture FY 2016 Updates Lecture 3M & Quantim Encoders Homework: Encoder Exercises Assign Case Studies Review Case Study Example Homework: Case Studies Test Unit VI, Form B Homework: Case Studies Case Studies Due Review Case Studies in class Demonstration: Computer Assisted Coding software (Tentative date) THE ABOVE OUTLINE MAY BE CHANGED AT THE DISCRETION OF THE INSTRUCTOR. The students will be informed in a timely manner in order to properly prepare for the class a FL 15 7

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