Course
Prefix/Number: ALHT 150
Course
Title: Billing and
Insurance
Division: Outreach and Workforce Development
Program: Health
Information Technology
Credit
Hours: 3.0
Initiation/Revised
Date: Fall
2007
CLASSIFICATION OF
INSTRUCTION
This
course involves the study of the principles and practice of insurance and
reimbursement processing. It includes
the assignment and reporting of codes for diagnoses and procedures/services;
completion of CMS-1450 and CMS-1500 claims for inpatient, outpatient, emergency
department, and physician office encounters; and the review of inpatient and
outpatient cases to identify issues of fraud and abuse. Textbook cases and redacted patient records
will be used to code diagnoses/services/procedures and complete claims. Inpatient and outpatient reimbursement will
be determined and source documents interpreted (e.g., explanation of benefits,
Medicare Summary Notices, and so on).
PREREQUISITIES AND/OR
COREQUISITES:
Health
Information Technology, Health Information Technology Lab, BIOL 257 Human
Anatomy & Physiology, BIOL 258 Human Anatomy & Physiology Lab, ALHE 122
Introduction to Pharmacology or Instructor consent, and ALHT 160 Billing Insurance Lab
REQUIRED
TEXTBOOKS:
Green, Michelle A
and J, Rowell. Understanding Health Insurance: A guide to billing and
reimbursement. Thomas Delmar Learning, Current year edition.
Buck, Carol J. ICD-9-CM and HCPCS Coding
Manual. Philadelphia, PA: Elsevier,
current edition
CPT,
Current Procedural Terminologies, Chicago, IL: American Medical Association,
current edition
Principles of Healthcare Reimbursement,
Castro & Layman, AHIMA, 2nd edition
COURSE OUTCOMES/COMPETENCIES (as Required)
a. Monitor coding and revenue cycle processes.
b. Explain insurance terms, including deductible, copay,
and other applicable terms.
c. Calculate case mix of selected patients
d. Prepare a case mix report
a. Code accurately for billing and reimbursement
procedures
b. Code for billing procedures in an outpatient facility,
including the RBRVS and RVUs, the completing of the UB92 forms, explanation of
insurance terms, and submission of bills; and correction and resubmission of
corrected information (appealing denials)
c. Accurately assign DRGs to Medicare inpatient
discharges.
d. Explain the effect modifiers have on reimbursement in
an outpatient facility.
a. Explain the necessity of correct information both for
the patient and the facility
AHIMA DOMAINS
Domain 1: Health Data
Management
Subdomain A: Health Data Structure,
Content and Standards
6. Verify timeliness, completeness, accuracy,
and appropriateness of data and data sources
(e.g., patient care; management; billing
reports and/or databases)
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 (e.g., APC; DRG; RVU; RBRVS)
3. Use established guidelines to comply with
reimbursement and reporting requirements
(e.g., National Correct Coding Initiative
[NCCI]; Local Medical Review Policies
[LMRP])
Domain 3: Health Services
Organization and Delivery
Subdomain A: Healthcare Delivery Systems
2. 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 and Systems
Subdomain A: Information and Communication
Technologies
1. Use technology, including hardware and software, to
ensure data collection, storage, analysis, retrieval and reporting of
information.
Domain 5: Organizational Resources
Subdomain B: Financial and Physical
Resources
3. Monitor coding
and revenue cycle processes.
I. Introduction
Health Insurance Processing
a. Health
Insurance Specialist – Roles and Responsibilities
b. Managed Health Care
c. Life Cycle of an Insurance Claim
d. Legal and Regulatory Considerations
II. ICD-9-CM
III. HCPCS Coding
a. CPT coding
b. National Level II coding
IV. Federal Reimbursement Issues
a. Inpatient reimbursement – DRGs
b. Outpatient reimbursement – APGs
c. Physician office reimbursement – RBRVS
d. Long term care reimbursement – RUG-III
e. Home health care reimbursement – OASIS
f. Fraud and abuse issues
V. Coding From Source Documents for Reimbursement
Purposes
a. Coding case studies
b. Coding redacted patient records
VI. CMS-1500 Claims Processing
a. Essential HCFA-1500 claim form instructions
b. Filing commercial claims
c. Blue Cross and Blue Shield Plans
d. Medicare
e. Medicaid
f. TRICARE
g. Workers’ Compensation
VII.
UB-04 (CMS-1450)
Claims Processing
a. Inpatient basis
b. Outpatient basis
c. Emergency department basis
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 |
Introduction Health
Insurance Processing |
Assignments |
|
2 |
ICD-9-CM |
Assignments |
|
3 |
HCPCS Coding |
Assignments |
|
4 |
CPT coding |
Assignments |
|
5 |
National Level II coding |
Assignments |
|
6 |
Inpatient reimbursement –
DRGs |
Assignments |
|
7 |
Outpatient reimbursement –
APGs |
Assignments |
|
8 |
Physician office
reimbursement – RBRVS |
Assignments |
|
9 |
Long term care
reimbursement – RUG-III |
Assignments |
|
10 |
Home health care
reimbursement – OASIS |
Assignments |
|
11 |
Fraud and abuse issues |
Assignments |
|
12 |
Coding From Source
Documents for Reimbursement Purposes |
Coding case studies Coding redacted patient records |
|
13 |
CMS-1500 Claims Processing |
Assignments |
|
14 |
CMS-1500 Claims Processing |
Assignments |
|
15 |
UB-04 (CMS-1450) Claims
Processing |
|
|
16 |
Final |
Final |
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, and 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 email address to succeed in this course.
Evaluation is directly related to the
performance objectives.
Performance is measured by examination,
assignments, and/or quizzes.
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
Seventy-five percent of the final grade is
based on chapter tests that evaluate knowledge of the text information and
ability to code patient services. Ten percent or five points (which is the
greater) will be deducted from each examination score that is not completed by
its due date. This rule reinforces the need for on-time performance. Any
make-up examination must be completed within 7 days of the scheduled
examination or no points will be awarded for the examination.
Twenty-five percent of the final grade is based on comprehensive final
examination scheduled during the semester’s designated finals week. Further details and information will be
provided closer to time of exam.
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.
ASSESSMENT OF STUDENT GAIN
Student
gain will be determined by student improvement in each of the areas of student
competencies.
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.
CELL PHONE POLICY:
Student cell phones and
pagers must be turned off during class times. Faculty may approve an exception
for special circumstances.
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, 620-431-2820, Ext. 213., or the
Dean, Ottawa Campus, 785-242-2607 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.
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.