Course Syllabus

COURSE IDENTIFICATION

Course Prefix/Number: ALHT 160

Course Title: Billing & Insurance Lab

Division: Outreach and Workforce Development

Program: Health Information Technology

Credit Hours: 1.0

Initiation/Revised Date: Fall 2007

CLASSIFICATION OF INSTRUCTION

Vocational

COURSE DESCRIPTION

This course provides hands on/skill application of the principles and practice of insurance and reimbursement processes. 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).

PREREQUISITES 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, ALHT 150 Billing & Insurance

TEXT/WEBSITE/RESOURCES

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.

COURSE OUTCOMES/COMPETENCIES (as Required)

1. Understand and apply policies and procedures for the use of clinical data required in reimbursement and prospective payment systems (PPS) in healthcare delivery.

a. Explain coding and revenue cycle processes.

b. Explain insurance terms, including deductible, copay, and other applicable terms.

c. Compare and contrast a calculated case mix of selected patients and a case mix report.

2. Demonstrate accuracy of billing through coding, chargemaster, claims management, and bill reconciliation processes.

a. Determine correct coding for billing and reimbursement procedures

b. Determine correct 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. Select and assign the accurate DRGs to Medicare inpatient discharges.

d. Explain the effect modifiers have on reimbursement in an outpatient facility.

3. Demonstrate the use established guidelines to comply with reimbursement and reporting requirements such as the National Correct Coding Initiative.

a. Explain the necessity of correct information both for the patient and the facility

COURSE OUTLINE

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	Assignments
16	Final	Final

INSTRUCTIONAL METHODS/GRADING/STUDENT REQUIREMENTS

AND METHODS OF EVALUATION

A cumulative point system is used. Your class assignments will include reading, review questions, written reports, case studies, Website research, projects, practice exercises, discussion questions, chapter quizzes and examinations. The chapter examinations will be a part of each learning unit and are completed after the unit assignments, and prior to starting the next unit. Possible points for written reports, case studies, projects, and exams will vary and tracking of your total points for each assignment or exam will be available on the course Website. Class assignments will be evaluated for accuracy, content, form, knowledge of subject matter, application of knowledge and ability to communicate effectively.

Class participation is an essential element to your success in this course. You are expected to complete practice exercises and respond to the discussion questions with at least one posting (5 points).

Complete assignments by the due date. Late assignments will be docked 10% and only accepted 1 day past due date. Make-ups for exams or assignments are only permitted under special circumstances and with prior approval by the instructor. Borderline grades will be viewed in terms of timely completion of assignments and class participation.

Total points accumulated during the semester will be calculated into a percent and graded on the scale below.

Letter grades will be given using the following scale:

A = 90-100%

B = 80-89%

C = 70-79%

D = 60-69%

F = 59% and below

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.

It is the responsibility of the student to properly drop the course. Students, who are still enrolled in this class after the final drop date, but fail to participate in class, are at risk for a failing grade. Your grade will be based on the total points accumulated through the last date of participation.

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.

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 (RHIT). The expectation for this class is for you to be professional and ethical – do your own work.

CELL PHONE POLICY:

Student cell phones and pagers must be turned off during class times. Faculty may approve an exception for special circumstances.

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 Introduction to Health Information is basic to understanding many of the other courses in the Health Information Technology program, a grade of C or better is required to continue the program

NOTE: If you are a student with a disability who may need accommodation(s) under the Americans with Disabilities Act (ADA), please notify the Director of Advising and Counseling, Chanute Campus, Student Union, 620-431-2820 ext 280 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.