DELAWARE TECHNICAL & COMMUNITY COLLEGE
Department: Allied Health/Science
Course Number and Title: HIT 121 – Ambulatory Care Coding/Reimbursement
Instructor Name: _____________________________________________
Phone #: _____________ E-mail: _______________
Pre-requisites: HIT 120 – Inpatient Coding/Reimburse
BIO 121 – Anatomy & Physiology II
Course Hours and Credits: 2:3:3
Course Description: This course includes the use of coded data in reimbursement
and payment systems appropriate to ambulatory care settings
and includes prospective payment systems, billing and
insurance procedures, and managed care/capitation systems.
(To be selected by each campus department)
Method of Instruction: Lecture/Lab
CORE COURSE PERFORMANCE OBJECTIVES
The student will be able to:
1. Evaluate health insurance principles (CCC5, PGC 1-4).
2. Describe the variety of ambulatory care insurance plans (CCC5 and 7, PGC 2).
3. Describe the difference between outpatient and inpatient coding (CCC5 and 6, PGC 1-4).
4. Assign codes for outpatient procedures (CCC5, 6 and 9, PGC 1-5).
MEASURABLE PERFORMANCE OBJECTIVES
1. Evaluate health insurance principles.
1.1 Explain the purpose of ambulatory care coding
1.2 Define common insurance terms
1.3 State four concepts of a valid insurance contract
1.4 Compare the classes of health insurance contracts
1.5 Describe an overview of outpatient reimbursement systems
1.6 Review and give examples of the following:
1.6.1 Preferred provider organization
1.6.2 Independent practice associations
1.6.3 Health Maintenance Organizations
1.7 Contrast capitation, fee for service, percent of charges and per diem
1.8 List four actions to prevent problems when given signature authorization for
1.9 Discuss the steps used to process an insurance claim
1.10 Describe reasons why claims are rejected
1.11 State when the Health insurance claim form may or may not be used
1.12 Contrast manual and electronic claim submission
1.13 Describe claims processing terminology for commonly used insurance
1.14 Describe appeal processes for denied claims for the provider and the payer
1.15 Describe the role of the state insurance commissioner
1.16 List various types of insurance fraud
1.17 Provide an example of a fraudulent claim under the Medicare program
2. Describe the variety of ambulatory care insurance plans.
2.1 Describe commercial insurance plans and claims procedures
2.2 Describe the following governmental insurance plans and claims
2.2.3 Maternal and child health programs
2.2.4 Champus/Tricare/ChampVA/Champus managed care
2.3 Describe the following disability insurance plans and claims procedures
2.3.1 Worker’s compensation
2.3.2 Individual or group disability insurance plans
2.3.3 Disability benefits for military or veteran
2.4 Describe workers’ compensations laws, including purpose, terminology,
who is covered, exceptions and types of benefits
2.5 Contrast workers’ compensation insurance and employer liability insurance
2.6 Define the role of OSHA related to workers’ compensation
2.7 Define non-disability, temporary disability, and permanent disability as it
relates to claims
2.8 Describe the CMS common procedure coding system
2.9 Explain the purpose and components of the commonly used medicolegal
forms and letters
2.10 State components necessary for a claim audit trail
3. Describe the difference between outpatient coding and inpatient coding.
3.1 Explain the difference in guidelines in choosing principal diagnosis for each
3.2 Explain the main difference between ICD-9 and CPT procedure codes
and which are used in inpatient/outpatient settings
3.3 Identify and explain four reasons outpatient settings are experiencing larger
volumes of patients
3.3.1 Increased technology
3.3.2 Less expensive to perform on an outpatient setting
3.3.3 Less invasive reducing infections and complications
3.3.4 Assembly-line medicine
4. Assign codes for outpatient procedures.
4.1 Identify principal diagnosis for outpatient claims according to American
Medical Association Guidelines
4.1.1 Identify and properly use the various sections located in the CPT manual.
22.214.171.124 CPT Nomenclature
126.96.36.199.1 E/M Guidelines
188.8.131.52.2 Anesthesia Guidelines
184.108.40.206.3 Surgery Guidelines
220.127.116.11.4 Radiology Guidelines
18.104.22.168.5 Pathology and Laboratory Guidelines
22.214.171.124.6 Medicine Guidelines
4.2 Identify and explain at least 4 different outpatient settings and their
unique coding challenges
126.96.36.199 ER Level of Care
188.8.131.52 Diagnosis coding for ER
184.108.40.206 Procedure coding for ER
4.2.2 Physician’s office
220.127.116.11 Super bill
18.104.22.168 Diagnosis coding
4.2.3 Hospital short procedure unit
22.214.171.124 ICD-9 Diagnosis coding
126.96.36.199 Coding for surgery using CPT
188.8.131.52 Understand APC reimbursement
4.2.4 Outpatient surgery centers
4.2.5 Hospital and freestanding outpatient facilities, lab, radiology, etc
4.3 Use the CPT manual index to find the correct procedure code.
4.4 Use CPT modifiers found in Appendix A in the CPT manual
4.5 Correctly code procedures using the CPT manual for:
4.5.1 Evaluation and Management
4.5.5 Pathology and laboratory
1. In order to achieve the maximum benefit from this course of instruction, the student is
responsible for attending scheduled classes, completing all readings and instructor
handouts, and actively participating in class discussion and activities.
2. The instructor will announce the schedule for written tests and quizzes.
3. Students will demonstrate proficiency on all measurable performance objectives at least
to the 75% level to successfully complete the course. The grade will be determined
using the College Grading System:
92 – 100 = A
83 – 91 = B
75 – 82 = C
0 – 74 = R
Students should refer to the DTCC Student Handbook and the Allied Health/
Science Department Policy Manual for information on Academic Standing Policy,
Academic Honesty Policy, Student Responsibilities and Student Rights, and other
policies relevant to their academic progress.