Health Information Technology
This course is designed to prepare a student to code in the hospital setting using ICD-10-CM/PCS. The course will emphasize reporting requirements for codes and rules that apply to reimbursement systems used by government payers and other health plans. The student will be introduced to computerized coding systems utilized in healthcare. The emphasis of the course will be development of intermediate skills to code accurately and ethically. Students will assign codes for diagnoses, services and procedures that are documented in the health/medical record. The student will use the encoding software in the laboratory to apply coding to health records.
(A requirement that must be completed before taking this course.)
Upon successful completion of the course, the student should be able to:
- Conduct analysis to ensure documentation in the health record supports the diagnosis and reflects the patient's progress, clinical findings and discharge status.
- Apply diagnosis/procedure codes using ICD-10-CM/PCS.
- Use electronic applications and work processes to support and maintain clinical classification and coding.
- Ensure accuracy of diagnostic/procedural groupings to confirm Medicare Severity Diagnosis Related Groups (MS-DRG) assignment.
- Adhere to current regulations and established guidelines in code assignment.
- Validate coding accuracy using clinical information found in the health record.
- Use applications and processes to support and maintain other clinical classification and nomenclature systems (such as ICD-10-CM, SNOMED and so on).
- Monitor coding and revenue cycle processes including case mix index.
- Resolve discrepancies between coded data and supporting documentation.
- Apply Present on Admission (POA) indicator guidelines.
- Utilize coding references such as "Coding Clinic" to clarify current coding issues.
- Apply policies and procedures for the use of clinical data required in reimbursement and prospective payment systems (PPS) in healthcare delivery.
- Apply policies and procedures to comply with the changing regulations among various payment systems for healthcare services such as Medicare, Medicaid, managed care and so forth.
- Support accurate billing through coding, chargemaster, claims management and bill reconciliation processes.
- Use established guidelines to comply with reimbursement and reporting requirements such as the National Correct Coding Initiative.
- Compile patient data and perform data quality reviews to validate code assignment and compliance with reporting requirements.
Currently no sections of this class are being offered.