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					                                                                     Proposed 2007-52


                               COURSE SYLLABUS

Campus:                     Collegewide

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.

Required Texts:
                            (To be selected by each campus department)


Method of Instruction:      Lecture/Lab




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).


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
                    insurance claims
             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
                   2.2.1 Medicare
                   2.2.2 Medicaid
                   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.
                  CPT Nomenclature
                         E/M Guidelines
                         Anesthesia Guidelines
                         Surgery Guidelines
                         Radiology Guidelines
                         Pathology and Laboratory Guidelines
                         Medicine Guidelines
           4.2     Identify and explain at least 4 different outpatient settings and their
           unique coding challenges
               4.2.1 ER
                  ER Level of Care
                  Diagnosis coding for ER

                  Procedure coding for ER
                 4.2.2 Physician’s office
                  Super bill
                  Diagnosis coding
                 4.2.3 Hospital short procedure unit
                  ICD-9 Diagnosis coding
                  Coding for surgery using CPT
                  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
                 4.5.2 Anesthesia
                 4.5.3 Surgery
                 4.5.4 Radiology
                 4.5.5 Pathology and laboratory
                 4.5.6 Medicine

Evaluation Criteria/Policies:

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.

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