I. General Information

1. Course Title:
Fundamentals of Coding and Reimbursement

2. Course Prefix & Number:
HINS 1146

3. Course Credits and Contact Hours:

Credits: 3

Lecture Hours: 3

Lab Hours: 0

4. Course Description:

This course will cover the coding and billing regulations affecting the health insurance industry. This course will give an overview of ICD-9-CM, ICD-10-CM, ICD-10-PCS, CPT and HCPCS coding. The students will apply coding skills to claim creation using processes established by the health insurance industry and coding guidelines/requirements. This course does not fulfill requirements within the Health Information Specialist diploma or Coding emphasis AAS degrees.

5. Placement Tests Required:

Accuplacer (specify test):

No placement tests required

Score:

6. Prerequisite Courses:

There are no prerequisites for this course.

9. Co-requisite Courses:

There are no corequisites for this course.

II. Transfer and Articulation

III. Course Purpose

1. Program-Applicable Courses – This course is required for the following program(s):

Health Informatics Specialist, AAS

Medical Assistant, Diploma

IV. Learning Outcomes

1. College-Wide Outcomes

College-Wide Outcomes/Competencies	Students will be able to:
Demonstrate written communication skills	List CMS outpatient guidelines in coding diagnosis.
Analyze and follow a sequence of operations	List the steps in processing an insurance claim using CMS 1500 formats.
Apply abstract ideas to concrete situations	Use a scenario to identify and properly use ICD-9-CM coding convention.

2. Course Specific Outcomes - Students will be able to achieve the following measurable goals upon completion of the course:

• List and apply CMS outpatient guidelines in coding diagnoses
• Identify and properly use ICD-9-CM coding conventions
• Accurately code diagnoses according to ICD-9-CM
• Explain the differences between ICD-9-CM and ICD-10-CM/PCS
• Explain the purpose of reporting diagnosis codes on insurance claims, including the concept of medical necessity.
• Assign CPT codes to procedures and services.
• Assign HCPCS level II codes and modifiers
• Explain hospital revenue management cycle
• Explain the characteristics of commercial insurance plans.
• Explain the difference between automobile, disability, and liability insurance.
• Describe the life cycle of an insurance claim.

V. Topical Outline

Listed below are major areas of content typically covered in this course.

1. Lecture Sessions

1. Introduction to Health Insurance
• Medical documentation
• Electronic health record
2. Managed Health Care
• Managed care organizations
• Managed care models
• Consumer directed health plans
• Accreditations of managed care organizations
• Effects of managed care on a physician practice
3. Processing an Insurance Claim
• New patients
• Established patients
• Insurance claim life cycle
• Electronic data interchange
• Maintaining insurance claim files
4. Legal and Regulatory
• Introduction to legal and regulatory considerations
• Federal laws and events that affect health care
• Retention of records
• HIPAA
5. ICD-9-CM Coding
• Medical necessity
• Overview of ICD-10-CM/PCS
• Outpatient coding guidelines
• ICD-9-CM coding systems
• ICD-9-CM index to diseases
• ICD-9-CM tabular list of diseases
• ICD-9-CM index to procedures and tabular lists of procedures
• ICD-9-CM index to disease tables
• ICD-9-CM supplementary classifications
• Coding special disorders according to ICD-9-CM
• Ensure accurate ICD-9-CM coding
6. CPT Coding
• CPT sections, subsections, categories and subcategories
• CPT index
• CPT modifiers
• Coding procedures and services
• Evaluation and management
• Anesthesia
• Surgery
• Radiology
• Pathology and laboratory
• Medicine
• National correct coding initiative
7. HCPCS Level II Coding
• Overview of HCPCS
• HCPCS Level II national codes
• Determining payer responsibility
• Assigning HCPCS Level II codes
8. CMS Reimbursement Methodologies
• CMS Payment Systems
• Clinical Laboratory Fee Schedule
• Hospital inpatient prospective payment system
• Hospital outpatient prospective payment system
• Medicare physician fee schedule
• Charge master
• Revenue cycle management
9. Coding for Medical Necessity
• Applying coding guidelines
• Coding and billing considerations
• Coding case scenarios
• Coding from patient reports
10. CMS-1500 Claim
• Insurance billing guidelines
• Optical scanning guidelines
• Reporting Diagnoses
• Reporting procedures and services
• Processing secondary claims
11. Commercial Insurance
• Commercial health insurance
• Automobile, disability and liability insurance
• Commercial claims
• Claim instructions commercial secondary coverage
12. Medicare
• Medicare plans
• Medigap
• Participating and non-participating providers
• Advance beneficiary notice (ABN)
• Experimental and investigational procedures
• Medicare summary notice
• Billing notes
• Medicare and Medigap claims
13. Medicaid
• Medicaid covered services
• Payment for Medicaid Services
• Claims instructions
• Medicaid as a secondary payor
• SCHIP claims
14. TRICARE/CHAMPVA
• TRICARE administration
• CHAMPVA
• TRICARE options, programs and demonstration projects
• Claims instructions
15. Workers’ Compensation
• Federal WC programs
• State WC programs
• Eligibility for WC coverage
• First report of injury form
• Progress report
• Appeals and adjudication
• Fraud and abuse
• Claims instructions

2. Laboratory/Studio Sessions

Textbooks
Author(s)	Title(s)	Publisher(s)	Edition/Date(s)
Green, Michelle A Rowell, JoAnn C	Understanding Health Insurance:  A Guide to Billing and Reimbursement	Delmar Cengage	10th