HIM 257 - Health Data Classifications Systems III
Course Description
Effective: 2019-01-01
Integrates and applies knowledge with hands-on skill practice in coding. Reinforces medical terminology, anatomy, and coding guidelines for International Classification of Diseases (ICD) and Current Procedural Terminology (CPT). Introduces the student to the Healthcare Common Procedure Coding System (HCPCS) coding guidelines. Promotes critical thinking related to coding quality, fraud, and abuse.
Lecture 3 hours. Total 3 hours per week.
3 credits
General Course Purpose
A requirement for the Medical Records Coder Career Studies Certificate and the Health Information Management AAS, the purpose of this course is to provide students with an opportunity to think critically about the application of knowledge and hands-on practice in the following areas: coding guidelines, quality of coded data, and potential fraud and abuse issues.
Course Objectives
- Demonstrate electronic applications skills to support clinical classification and coding (i.e., encoders)
- Discuss the history of the development of clinical vocabularies
- Classify diagnosis and procedure codes using the ICD official guidelines
- Establish principal diagnosis (inpatient) or first listed (outpatient)
- Establish and assign secondary diagnosis(es), including complications and comorbidities (CC)
- Differentiate between principal and secondary procedures and assign appropriate procedure code
- Apply appropriate CPT coding guidelines
- Identify discrepancy issues with coding and missing supporting documentation
- Identify documentation that can and cannot be utilized for coding purposes
- Compile and utilize reference materials to facilitate accurate code assignment
- Describe the use and coding process for HCPCS
- Review medical terminology and anatomy
Major Topics to be Included
- Quality of coded data
- ICD coding guidelines
- CPT coding guidelines
- HCPCS coding guidelines
- History, use, and structure of classification systems
- Medical terminology and anatomy
- Principal diagnosis, complications, and comorbidities
- Encoders