Course Syllabus
Course Prefix/Number: ALHT 240
Course Title: Acute/Long Term/Specialty Coding
Division: Outreach and Workforce Development
Program: Health Information Technology
Credit Hours: 3.0
Initiation/Revised: Fall 2007
Instructor: Karma Michael, RHIA
Vocational
This course provides the student the purpose and use of the ICD-9-CM classification system. Topics include coding conventions, coding principles, and CMS official coding guidelines (inpatient and outpatient). Students will be required to assign ICD-9-CM codes to diagnosis/procedure statements, case abstracts, and patient records. Inpatient, long term care, specialty coding, ICD-O and an introduction to ICD-10 are covered.
BIOL 257 Human Anatomy & Physiology, BIOL 258 Human Anatomy & Physiology Lab, NURS 230 Pathophysiology, ALHE 105 Medical Terminology, ALHE 122 Introduction to Pharmacology, ALHT 130 Intro to Medical Coding, ALHT 230 Ambulatory Coding, or Instructor consent and ALHT 245 Acute/Long Term/Specialty Coding Lab.
Johns, Merida L., PhD, RHIA, ed. Health Information Management Technology: An Applied Approach. Chicago: American Health Information Management Association, 2007.
Brown, Faye. ICD-9-CM Coding Handbook for Entry Level Coders. Chicago, IL: American Hospital Association, current edition.
Channel Publishing, ICD-9-CM Educational Annotation for Hospital, Vol 1, 2, 3 softbound, Albany, NY: Channel Publishing, current edition.
Conditions of participation for Hospitals and Long-Term Care Facilities
Journal of the Health Information management Association
Cancer Program Manual, current edition, American College of Surgeons
ROADS Manual, American College of Surgeons
Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association
1. Explain the importance of and appropriately
use of the Coding Clinics as directed in
the coding manual.
a. Apply policies and procedures for the use of
clinical data required in
reimbursement and prospective payment systems (PPS) in healthcare
delivery.
2. Determine discrepancies between coded data
and supporting documentation.
3. Use specialized software in the completion of
HIM processes (e.g., coding, grouping,
and billing).
a. Use
and maintain electronic applications and work processes to support clinical
classification and coding (e.g., ICD-9-CM).
b. Understand the different between Standard
Nomenclature of Disease and Operations (SNDO), Systematized Nomenclature of
Pathology (SNOP) and Systematized Nomenclature of Medicine (SNOMed)
4. Determine the appropriate code for the
medical record
a.
Locate and differentiate between admitting diagnoses and final
diagnoses.
b.
Locate forms in the chart for refining of diagnoses, such as radiology
and
pathology report information.
c.
Compare and contrast diagnostic information located on the face sheet,
discharge
summary, progress notes, pathology
report, surgical reports, and radiology reports,
and select the most appropriate,
complete, or detailed diagnosis.
d.
Identify and correct select the following in given diagnostic and
procedural
scenarios: principal diagnosis, other
diagnosis, complication, comorbidity,
symptom, uncertain diagnosis,
principal procedure, significant procedure.
e.
Formulate the appropriate sequence to code principal diagnosis and
procedures
f.
Using the ICD-9-CM coding manual to identify neoplasm coding rules,
accurately
code diagnoses and procedures to
inpatient or outpatient charts.
g. Assign the appropriate V codes as needed.
h.
Assign appropriately the morphology codes when indicated.
i. Using the ICD-9-CM coding manual, accurately
code diagnoses and procedures to
obstetrical and newborn to inpatient
charts.
j.
Assign appropriately the outcome of delivery codes.
k.
Explain the difference between antenatal, delivery, and postpartum
conditions.
l.
Using the ICD-O Coding manual, accurately assign both site and
morphology
codes to cancer cases.
m. Using both the TMR and SEER staging
systems, accurately assign stages to cancer
cases.
5. Explain the purpose of the cancer registry.
a.
Case identification accession registers.
b.
Patient indexes.
c.
Follow up.
d.
State and Regional registries.
6. Explain MDS analysis.
a.
Explain the contents of each section and how to complete each.
b.
Analyze the data about a nursing home resident, and indicate omissions
or
incorrectly completed data.
7. Explain HCPCS Level II codes
a.
Explain services, equipment and supplies that are codable
with HCPCS Level II
codes.
b.
Using the HCPCS Level II manual, correctly assign the Level II codes for
services,
equipment, and supplies.
8. Explain and demonstrate how to abstract intensity of service and severity of illness
criteria.
9. Demonstrate knowledge
of UHDDS definitions of coding to accurately assign and
sequence codes.
10.
Demonstrate a basic
understanding of ICD-10.
AHIMA DOMAINS
Domain I: Health Data Management
Subdomain A. Health Data Structure, Content and Standards
3. 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 (e.g., APC; DRG; IPF)
5. Adhere to current regulations and established guidelines in code assignment
6. Validate coding accuracy using clinical information found in the health record
7. Identify discrepancies between coded 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 (e.g., APC; DRG; RVU; RBRVS)
2. Support accurate revenue cycle through:
a. Coding
3. Use established guidelines to comply with reimbursement and reporting requirements (e.g., National Correct Coding Initiative {NCCI}; Local Medical Review Policies {LMRP})
Domain 2: Health Statistics, Biomedical Research and Quality Management
1. Abstract and maintain data for clinical indices/databases/registries
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
3. Use specialized software in the completion of HIM processes (e.g., chart management; coding; release of information)
Domain 5: Organizational Resources
Subdomain B. Financial and Physical Resources
4. Monitor coding and revenue cycle processes
I. Introduction to Classification Systems
A. Purpose of classifications
B. Nomenclatures versus classification
C. Historical development of coding systems
II. ICD-9-CM
A. Tabular List, Index to Diseases, Tabular List and Index to Procedures
B. Section headings, and category, subcategory, subclassification codes
C. Coding conventions
D. Coding principles
E. Coding diagnosis/procedure statements, case studies, and records
1. Infectious and parasitic diseases
2. Neoplasms
3. Endocrine, nutritional and metabolic diseases
4. Diseases of the blood and blood-forming organs
5. Mental disorders
6. Diseases of the nervous system and sense organs
7. Diseases of the circulatory system
8. Diseases of the respiratory system
9. Diseases of the digestive system
10. Diseases of the genitourinary system
11. Complications of pregnancy, childbirth and puerperium
12. Diseases of the skin and subcutaneous tissue
13. Diseases of musculoskeletal system and connective tissue
14. Congenital anomalies
15. Certain conditions originating in the perinatal period
16. Symptoms, signs and ill-defined conditions
17. Injury and poisoning
18. V-codes
19. E-codes
20. Procedures
F. Patient record abstracting
G. Data quality
III. Coding and Reimbursement
A. DRGs, LTC-DRGs
B. Encoders, groupers, and UB-04 claims completion software
IV. ICD-10
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/Review, other classifications |
TBA |
|
2 |
Coding Conventions and UHDDS |
Brown Chapters 1, 2, 3 |
|
3 |
Coding Steps and Guidelines |
Brown Chapters 4, 5, 6 |
|
4 |
Procedure Coding Guidelines, V&E coding, Coding signs and symptoms |
Brown Chapters 7, 8, 9, Online cases |
|
5 |
Infectious Diseases, Endocrine System |
Brown Chapter 10 & 11, online cases |
|
6 |
Mental & Psych, Disease of Blood, Nervous System |
Brown Chapter 12, 13 & 14 online cases |
|
7 |
Respiratory System, Digestive Systems |
Brown Chapter 15 & 16, online cases |
|
8 |
Genitourinary System, Skin, Musculoskeletal |
Brown Chapters 17, 18, & 19, online cases |
|
9 |
Pregnancy & Prenatal |
Brown Chapters 20-23, online cases |
|
10 |
Circulatory & Neoplasms |
Brown Chapters 24 & 25, online cases |
|
11 |
Injuries, Burns, Poisoning |
Brown Chapters 26-28, online cases |
|
12 |
Complications, Intro to ICD-10 |
Brown Chapters 29-34, online cases |
|
13 |
DRG’s & Chargemaster |
Online reading assignments |
|
14 |
Final Examination |
Full Patient Charts and Case Studies |
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.
90-100% = A
80-89% = B
70-79% = C
60-69% = D
59% and below = F
Absences that occur due to
students participating in official college activities are excused. Students who
are excused will be given reasonable opportunity to make up any missed work or
receive substitute assignments from the instructor. Ultimately it is the student’s responsibility
to notify the instructor in advance of the planned absence.
Unless students are excused by the
instructor, they are expected to attend class. Students who are absent for two
consecutive weeks (prior to the final drop date) and fail to contact the
instructor may be dropped from this class.
If a 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.
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. 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.