School of Health Sciences HEALTH INFORMATION TECHNOLOGY Course: HIT 1020 - Basic Diagnosis Coding Credit Hours: 3cr hours Instructor: TBA Office Phone: Division of Allied Health (801) 957-6200 Office Hours: TBA PREREQUISITES: None RECOMMENDED CO-REQUISITES: HIT 1010, HIT 1040, HIT 1030 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 ICD-10-CM Standard Edition DRAFT (Softbound), Current Edition, by Carol J. Buck, Saunders ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Current Edition, by Carol J. Buck, Saunders COURSE DESCRIPTION Introduction and practice with International Classification of Diseases using current (ICD-9) coding procedures as well as instruction toward ICD-10 implementation and HCPCS for optimal reimbursements as practiced in the medical setting. Course material is presented in online lecture format as well as the presentation and discussion of patient care scenarios to enhance the learning process. Materials, coding resources, CD and textbook based programs are used to provide patient case reports and hospital operative procedures. COURSE FOCUS The course focus is learning the basic coding rules for ICD-10-CM, ICD-9-CM, and then applying the rules to code patient diagnoses. In addition, a variety of payment systems are presented, such as MS-DRG, APC, and RUGSIII. The medical topics of Medicare fraud/abuse, HMOs, and PROs are also reviewed. A brief overview of inpatient coding and the reporting of facility services provided to patients in acute inpatient facilities and the reporting of these services with ICD-10-PCS and ICD-9-CM, Volume 3, Procedure codes. (To present this course requires 1
anatomy, physiology, pathophysiology and terminology to be sequenced concurrently so that the specific system/material is presented along with the coding of the system). Methods include online discussion and lectures format, demonstrations and media presentations. The following list of Course Competencies/Objectives further describes this focus. COURSE OBJECTIVES UNIT #1 Reimbursement CHAPTER #1 Reimbursement, HIPAA, and Compliance Week One Distinguish among Medicare Part A, B, C, and D. Interpret rules of the Health Insurance Portability and Accountability Act (HIPAA) Locate information in the Federal Register. Explain the RBRVS system Understand the framework of Medicare Fraud and Abuse. Identify the major components of Managed Health Care. UNIT #2 ICD-10-CM CHAPTER #2 Overview of ICD-10-CM Week Two Explain the development of the ICD-10-CM. Describe how the ICD-10-CM replaces the ICD-9-CM, Volumes 1 and 2. Identify the improvements in the ICD-10-CM. List the official instructional notations in ICD-10-CM. Analyze the ICD-10-CM Official Guidelines for Coding And Reporting. Describe the format of ICD-10-CM. CHAPTER #3 ICD-10-CM Outpatient Coding and Reporting Guidelines Week Three Identify a first-listed diagnosis. Define assignment of codes for unconfirmed diagnosis. Describe code assignment for outpatient surgery. Outline assignment of additional diagnoses. Describe Z code reporting. Define observation stay. Delineate the differences between first-listed and coexisting conditions. Explain uncertain diagnosis. Understand assignment of codes for chronic diseases. Recognize diagnostic services. Recognize therapeutic services. Illustrate reporting of preoperative evaluations. Explain prenatal visits. Apply the Official Guidelines for Coding and Reporting. CHAPTER #4 Using ICD-10-CM Week Four Demonstrate ability to utilize the Alphabetic Index and Tabular List. 2
Understand the steps to accurate coding. Comprehend the organization of the Guidelines. Use both the Alphabetic Index and Tabular List. Outline the need for level of specificity in diagnosis coding. Identify conditions integral to a disease process. Assign multiple codes to a single condition. Report acute and chronic conditions. Demonstrate application of combination codes. Differentiate between residual and late effects. Abstract information that determines if a condition is impending or threatened. Outline the rules when reporting the same diagnosis code more than once. Assign codes based on laterality. CHAPTER #5 Chapter Specific Guidelines (ICD-10-CM Chapters 1-10) Week Five Review certain infectious and parasitic disease codes. Analyze neoplasm codes. Assess the blood and blood-forming organs and certain disorders involving the immune mechanism codes. Examine the endocrine, nutritional, and metabolic diseases codes. Understand the mental and behavioural disorders codes. Examine the diseases of the nervous system codes. Analyze the diseases of the eye and adnexa codes. Comprehend the organization and reporting of the ear and mastoid process codes. Recognize the diseases of the circulatory system codes. Evaluate the diseases of the respiratory system codes. Demonstrate the ability to report diagnoses with I-10 codes for Chapter 1-10. CHAPTER #6 Chapter Specific Guidelines (ICD-10-CM Chapters 11-14) Week Six Examine the digestive system coding. Review coding the skin and subcutaneous tissue diseases. Understand diseases of the musculoskeletal system and connective tissue coding. CHAPTER #7 Chapter Specific Guidelines (ICD-10-CM Chapters 15-21) Week Seven Review the pregnancy, childbirth, and puerperium coding. Report services of certain conditions originating in the perinatal period. Examine the congenital malformations, deformities and chromosomal abnormalities. Define the rules of symptoms, signs, and abnormal clinical and laboratory findings that are not elsewhere classified. Identify the elements of coding injury, poisonings and certain other consequences of external causes. UNIT #3 ICD-9-CM CHAPTER #8 An Overview of ICD-9-CM Week Eight List the uses of the ICD-9-CM. 3
Identify the characteristics of the Tabular List, Volume 1. Identify the characteristics of the Alphabetic Index, Volume 2. Explain the uses of coding conventions when assigning codes. Identify the characteristics of the Procedures Index and Tabular List, Volume 3. Demonstrate use of ICD-9-CM. CHAPTER #9 ICD-9-CM Outpatient Coding and Reporting Guidelines Week Nine Identify the first-listed diagnosis. Demonstrate ability to assign diagnoses codes to unconfirmed conditions. Assign the first-listed diagnosis in the outpatient surgery setting. Report first-listed diagnoses in the observation setting. Validate V code assignment. Apply codes to suspected conditions. Report uncertain diagnoses. Demonstrate ability to report chronic conditions. Examine guidelines for reporting therapeutic services. Evaluate diagnoses reporting for surgical procedures. Identify the Guidelines for reporting prenatal visits. CHAPTER #10 Using ICD-9-CM Week Ten Explain the organization of the Guidelines. Determine the level of highest specificity. Identify conditions integral to a disease process. Assign multiple codes to a single condition. Report acute and chronic conditions. Demonstrate application of combination codes. Differentiate between residual and late effects. Abstract information that determines if a condition is impending or threatened. CHATPER #11 Chapter Specific Guidelines (ICD-9-CM Chapters 1-8) Week Eleven Review infectious and parasitic diseases coding. Analyze neoplasm coding. Examine the endocrine, nutritional, metabolic diseases, and immunity disorders coding. Review the blood conditions, mental, behavioral and neurodevelopmental disorders, nervous system, and sense organs coding. Review the circulatory system coding. Review the respiratory system coding. CHAPTER #12 Chapter Specific Guidelines (ICD-9-CM Chapters 9-17) Week Twelve Examine the digestive system coding. 4
Analyze the genitourinary system coding. Review the pregnancy, childbirth, and puerperium coding. Review skin and subcutaneous tissue coding. Review musculoskeletal and connective tissue coding. Examine the congenital anomalies and certain conditions originating in the perinatal period coding. Define the rules of symptoms, signs, and ill-defined conditions coding. Identify the elements of coding injuries and poisonings. UNIT #4 Inpatient Coding CHAPTER #31 Inpatient Coding Week Thirteen Explain the differences between inpatient and outpatient coding. Define principal diagnosis and procedure. Examine the Official Guidelines for Coding and Reporting. Review the Guidelines for selection of a Principal Diagnosis. Determine when a condition should be reported as an additional diagnosis. Explain the purpose of the present on admission indicators. Examine the ICD-10-PCS System. COURSE EVALUATION Class will focus on online lecture-discussion, structured group activities, and other activities that will enhance the learning process. Students are evaluated on performance on online test scores and online assignments. 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. 95-100% A 74-76% C PASSING 90-94% A- 70-73% C- 87-89% B+ 67-69% D+ 84-86% B 64-66% D 80-83% B- 60-63% D- 77-79% C+ 0-59% E Tests are worth 100 points, students workbook chapters are worth 20 points, for a total of 260 points for all chapters. 5
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. Emails will be sent through the course site. Check your email often. 2. If you have questions, e-mail the instructor, using the course email 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 email 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; 957-6406 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 801-957-5555. STUDENT CODE OF CONDUCT: The student is expected to follow the SLCC Student Code of Conduct found at http://www.slcc.edu/policies/docs/stdtcode.pdf Code of conduct violations are taken very seriously. Please consult with the OTA Student Handbook for details. ADA STATEMENT: http://www.slcc.edu/drc 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, 84123. Phone: (801) 957-4659, TTY: 957-4646, Fax: 957-4947. 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 6
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 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 Open and review of course 14 Jan 21 Unit 1-Chapter 1 Module 1.1 Module 1.2 Quiz #1 Jan 28 Module 1.3 Unit 2-Chapter 2 Module 2.1 Module 2.2 Quiz #2 Feb 4 Unit 2-Chapter 3 Quiz #3 7
Feb 11 Feb 18 Feb 25 Mar 4 Mar 11 Mar 18 Mar 25 Module 3.1 Module 3.2 Unit 2-Chapter 4 Module 4.1 Module 4.2 Unit 2-Chapter 5 Module 5.1 Module 5.2 Module 5.3 Unit 2-Chapter 6 Module 6.1 Module 6.2 Unit 2-Chapter 7 Module 7.1 Module 7.2 Module 7.3 Midterm Exam Spring Break Unit 3-Chapter 8 Module 8.1 Module 8.2 Module 8.3 Apr 1 Unit 3-Chapter 9 Module 9.1 Module 9.2 Apr 8 Unit 3-Chapter 10 Module 10.1 Module 10.2 Apr 15 Apr 22 Apr 29 May 6 Unit 3-Chapter 11 Module 11.1 Module 11.2 Module 11.3 Unit 3-Chapter 12 Module 12.1 Module 12.2 Module 12.3 Unit 4-Chapter 31 Module 31.1 Module 31.2 Module 31.3 Final Exam Quiz #4 Quiz #5 Quiz #6 Quiz #7 Midterm Exam Spring Break Quiz #9 Quiz #10 Quiz #11 Quiz #12 Quiz #13 Quiz #14 Final Exam 8