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METROPOLITAN COMMUNITY COLLEGE COURSE OUTLINE COURSE TITLE: Clinical Coding I COURSE PREFIX AND NO. HCIA 2421 LEC 4.5 LAB 0 CREDIT HOURS 4.5 COURSE DESCRIPTION: Students gain knowledge of the International Classification of Diseases, Clinical Modification (ICD-9CM and ICD-10-CM) systems, official coding guidelines, and application of coding principles to diagnostic statements found across the continuum of healthcare. Students explore utilization of coding resources and tools. The course includes hands-on activities with coding software. COURSE PREREQUISITE (S): `HIMS 1180, HIMS 1310, HIMS 1410, HCIA 1030 RATIONALE: Coding establishes medical necessity and translates it into a universal language. ICD-9-CM and ICD10-CM coding systems are used by all health care providers to substantiate the need for patient care or treatment and to provide statistics for morbidity and mortality rates. REQUIRED TEXTBOOK (S) and/or MATERIALS: Title: Edition: Author: 3-2-1 Code It Current Michelle A. Green, MPS, RHIA, FAHIMA, CPC Title: Edition: Author: Materials: 3-2-1 Code It Workbook Current Michelle A. Green, MPS, RHIA, FAHIMA, CPC Provided by Instructor, AHIMA Virtual Lab Encoder (furnished through Instructor) Attached course outline written by: Dawn Goodselll Revised by: Date: Effective Date: Academic Dean: Date: 10/12 Fall/2013 Dr. Thos C. Pensabene Metro Community College Date: Page 1 of 6 10/25/2012 TITLE: PREFIX/NO.: HCIA 2421 Clinical Coding I COURSE OBJECTIVES: Upon successful completion of this course, students should be able to: 1. Identify the professional organizations that serve as a resource for coding and offer coding credentials. 2. Utilize the ICD-9-CM and ICD-10-CM coding guidelines, coding books, references and General Equivalence Mapping (GEMS) crosswalk. 3. Define the abbreviations, punctuation, and other coding conventions used in ICD-9-CM and ICD-10-CM. 4. Apply ethical and compliance rules to coding practice. 5. Apply the following principles in determining ICD-9-CM and ICD-10-CM codes. a. Combination coding, b. Manifestation c. Disease processes d. Infectious disease coding 6. Describe the steps used to locate a disease code in ICD-9-CM and ICD-10-CM. 7. Assign disease codes using either a code book or a computerized encoder. TOPICAL UNIT OUTLINE/UNIT OBJECTIVES: UNIT I: A. B. C. D. E. UNIT II: A. OVERVIEW OF CODING Coding career Professional associations and credentials for coders Coding overview 1. Coding references 2. Computer assisted coding Documentation as basis for coding 1. Patient record formats 2. Manual record formats 3. Automated record formats Healthcare data collection 1. Reporting hospital data 2. Reporting physician office data INTRODUCTION TO ICD-9-CM/ICD-10-CM CODING Overview of ICD-9-CM and ICD-10-CM/PCS 1. General Equivalence Mapping (GEMS) Metro Community College Page 2 of 6 10/25/2012 B. C. D. UNIT III: A. B. C. D. E. F. G. H. I. J. K. L. UNIT IV: A. B. C. D. E. F. G. H. 2. Coding manuals 3. Updating ICD-9-CM and ICD-10-CM/PCS 4. Mandatory reporting of ICD-9-CM/ICD-10-CM 5. Medical necessity ICD-9-CM Tabular List of Diseases and ICD-10-CM Tabular List of Diseases and Injuries 1. Format and Structure of ICD-9-CM 2. Format and Structure of CD-10-CM 3. ICD-9-CM V codes 4. ICD-9-CM E Codes ICD-9-CM /ICD-10-CM index to diseases and injuries 1. Main terms, sub-terms, and qualifiers 2. Basic steps for using the index to diseases Official ICD-9-CM and ICD-10-CM guidelines for coding and reporting ICD-9-CM AND ICD-10-CM CODING CONVENTIONS Format and typeface Eponyms Abbreviations Punctuations Boxed notes Tables Includes notes Excludes notes Inclusion terms Other, other specified and unspecified codes Etiology and manifestation rules And, due to, in and in (due to); with, cross-references ICD-9-CM AND ICD-10-CM CODING GUIDELINES Official Guidelines for Coding and Reporting 1. Level of detail of coding; conditions that are an integral part of a disease process 2. Conditions that are not an integral part of a disease process 3. Multiple coding for a single condition; acute and chronic conditions; combination codes, late effects, impending or threatened condition. 4. Reporting same diagnosis code more than once. 5. Admission encounters for rehabilitation 6. Documentation for body mass index (BMI) and pressure ulcer stages ICD-9-CM: Specific Guidelines or Diagnosis Coding (001-139) Infectious and Parasitic Disease ICD-9-CM: Neoplasm (140-239) ICD-9-CM: Endocrine Nutritional and Metabolic Diseases and Immunity Disorders (240-279) ICD-9-CM: Diseases of the Blood and Blood Forming Organs (280-289) ICD-9-CM: Mental Disorders (290-319) ICD-9-CM: Diseases of the Nervous System and Sense Organs (320-389) ICD-9-CM: Diseases of the Circulatory System (390-459) Metro Community College Page 3 of 6 10/25/2012 I. J. K. L. M. N. O. P. Q. R. S. T. UNIT VIII: A. B. UNIT IX: A. B. C. UNIT X: ICD-9-CM: Diseases of the Respiratory system (459-519) ICD-9-CM: Diseases of the Digestive System (520-579) ICD-9-CM: Diseases of the Genitourinary System (580-629) ICD-9-CM: Complications of Pregnancy, Childbirth, and Puerperium (630-677) ICED-9-CM: Disease of the Skin and Subcutaneous Tissue (680-709) ICD-9-CM: Diseases of the Musculoskeletal and Connective Tissue (710-739) ICD-9-CM: Congenital Anomalies (740-759) ICD-9-CM: Certain Conditions Originating in the Perinatal Period (760-779) ICD-9-CM: Signs, Symptoms, and Ill-Defined Conditions (780-799) ICD-9-CM: Injury and Poisoning (800-999) V-codes E-codes INPATIENT HOSPITAL CODING Acute care facilities (hospitals) Inpatient diagnosis coding guidelines OUTPATIENT AND PHYSICIAN OFFICE CODING Outpatient care Diagnostic coding and reporting guidelines for outpatient services: hospital-based and physician Office Coding Guidelines for Outpatient Diagnostic Tests ICD-9-CM AND ICD-10-CM WRAP UP COURSE REQUIREMENTS/EVALUATION: Upon successful completion of the objectives for this course, students will have acquired basic cognitive knowledge of ICD-9-CM and ICD-10-CM coding to establish medical necessity, translate written terminology or descriptions into a universal, common language, and provide data for statistical analysis. ADDITIONAL RESOURCES: AMA AHIMA www.ama-assn.org www.ahima.org NLM (National Library of Medicine) www.nlm.nih.gov HCFA www.hcfa.gov Managed links www.managedhealthlinks.com National Center for Health Statistics (ICD-9-CM diagnosis codes) www.cdc.gov/nchswww Metro Community College Page 4 of 6 10/25/2012 OUTCOME ASSESSMENTS HCIA 2421 COURSE OBJECTIVES ASSESSMENT MEASURES 1. Identify the professional organizations that serve as a resource for coding and offer coding credentials. Test and activities 2. Utilize the ICD-9-CM and ICD-10-CM coding guidelines, coding books, references and General Equivalence Mapping (GEMS) crosswalk Test and activities 3. Define the abbreviations, punctuation, and other coding conventions used in ICD-9-CM and ICD-10-CM. Test and activities 4. Apply ethical and compliance rules to coding practice. Test, lab, and activities 5. Apply the following principles in determining ICD-9-CM and ICD-10-CM codes. a. Combination coding, b. Manifestation c. Disease processes d. Infectious disease coding Test, lab, and activities 6. Describe the steps used to locate a disease code in ICD-9-CM and ICD-10-CM. Test, lab, and activities 7. Assign disease codes using either a code book or a computerized encoder. Test, lab, and activities Metro Community College Page 5 of 6 10/25/2012 WEEK ASSIGNMENT Begin Module 1 assignments are due by the beginning of Module 2 1 All Module 1 assignments due-Begin Module 2 2 All Module 2 assignments due-Begin Module 3 3 All Module 3 assignments due-Begin Module 4 4 All Module 4 assignments due-Begin Module 5 5 All Module 5 assignments due-Begin Module 6 6 All Module 6 assignments due-Begin Module 7 7 8 All Module 7 assignments due-Begin Module 8 Research Project Due All Module 8 assignments-Begin Module 9 9 All Module 9 assignments-Begin Module 10 10 11 All Module 10 assignments due Final Exam Metro Community College Page 6 of 6 10/25/2012