Course Description

Effective: 2016-11-01

General Course Purpose

The purpose of the course is to introduce new concepts and assist students in applying sound coding principles to the following topics: Quality of coded data; Healthcare fraud and abuse; Prospective payment systems; Classification/language systems: ICD, ICD-10-CM/PCS, ICD-O, ICIDH, DSM, SNOMEDCT, Reed, UMLS and others; and current USA insurance/reimbursement systems This course is a requirement of the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) which is the accrediting organization for degree-granting programs in health informatics and information management. The course will be offered to any student that meet the prerequisites and/or are enrolled in the Health Information Management (HIM) or Clinical Data Coding (CDC) programs.

Course Objectives

• Quality of coded data
• Identify the steps necessary for thorough record review for complete and correct coding; with key coding principles and official guidelines in building a quality assessment/performance improvement system
• Illustrate the importance of timeliness processes on economic well-being of healthcare facility (the effects of accounts receivables and importance of remittance advice)
• Apply the encoder (i.e. 3M, Quantim) for correct coding assignment, ethical optimization the impact of concurrent versus retrospective coding
• Outline the steps in coder recruitment, training, monitoring and retention
• Assess the importance of the federal initiative in coding quality and fraud investigation (Inspector General's work plan; demonstrate knowledge in developing an organizational compliance plan)
• Prospective payment systems
• Examine the components of DRGs, APCs and APGs and prospective payment in the acute care hospital environment (historical development, structure, correct determination, monitoring, professional and ethical issues facing HIM professionals)
• Evaluate the major prospective payment systems used in other healthcare settings (IPPS, HHRGs, RUGs, RICs) (historical development, structure, correct determination, monitoring, professional education)
• Differentiate between capitation and risk adjusted methodologies of payment systems
• Other classification/language systems
• Analyze the development and implementation strategy of ICD-10-CM and ICD-10-PCS and other classification systems in IC family, specifically ICD-O and ICIDH
• Determine the core structure of DSM, SNOMED/CT and Reed classifications and the importance of language development in UMLS
• Current USA insurance and reimbursement systems
• Differentiate the key concepts of the types of insurance and third party payer reimbursement in US marketplace.
• Compare the reimbursement basics in the physician office setting (HCPCS and RBRVS) and evaluate the development and maintenance of the charge-master, account receivables and process of managing claims after initial submission

Major Topics to be Included

• Healthcare fraud/Inspector General work plan
• Quality of coded data
• Prospective payment: acute care hospital system
• Prospective payment: ambulatory and other healthcare settings
• Ethical issues in prospective payment
• Key concepts in insurance and reimbursement
• Types of third party payers and insurance processing
• Physician service reimbursement
• Claims and Accounts receivable management
• Reimbursements impact on managed care