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Advanced Hospital Coding and CCS Prep

GES 104 -- 80 hours

Course Objectives

• Understand how health information travels within departments of a facility.
  
• List the types of healthcare professionals, both administrative and clerical.
  
• Define the roles and responsibilities of a coder in both in- and out-patient facilities.
  
• Understand the standards, ethics and legal responsibilities of a coder.
  
• Learn the opportunities available for coders, and the importance of credentialing.
  
• Learn to interpret health-record documentation using knowledge of anatomy, physiology, clinical disease processes and medical terminology.
  
• Determine when additional clinical information is needed.
  
• Obtain further clinical information to assist with code assignment.
  
• Consult reference materials to facilitate code assignment.
  
• Identify patient encounter type(s) to assign codes.
  
• Identify etiology and manifestation(s) of clinical conditions.
  
• Learn the current coding and reporting requirements for inpatient services.
  
• Interpret conventions, formats, instructional notations, tables and definitions of the classification system to select diagnoses, conditions, problems, or other reasons for encounter.
  
• Sequence diagnoses and other encounter reasons according to notations and conventions of the classification system and standard data set definitions (UHDDS - Uniform Hospital Discharge Data Sets).
  
• Determine if signs, symptoms or manifestations require separate code assignments.
  
• Recognize when classification system does not provide a precise code for the condition documented (residual categories or non-classified syndromes).
  
• Select principal diagnosis, principal procedure, complications and comorbid conditions and other significant procedures that require coding according to UHDDS definitions and official coding guidelines.
  
• Evaluate the effect of code selection on Diagnosis Related Group (DRG_ assignment.
  
• Verify DRG assignment based on Prospective Payment System (PPS) definitions.
  
• Apply guidelines for bundling and unbundling of codes.
  
• Determine proper use of Modifiers, CPT vs. HCPCS Level II codes and Medical Necessity (linking diagnosis to procedure/service).
  
• Assess quality of coding.
  
• Understand reimbursement methodologies and documentation rules and regulations.
  
• Analyze health-record documentation for quality and completeness of coding.
  
• Evaluate health-record documentation to substantiate claims processing and appeals.
  
• Understand the differences between the hospital Inpatient and Outpatient Record, and identify outpatient record components.
  
• Identify the Charge Master and its components.
  
• Understand the CPT guidelines, with special emphasis on Evaluation and Management (E&M) and surgery coding.
  
• Identify coding considerations and guidelines for diagnostic tests.
  
  CODING COMPETENCIES - Hospital-based competencies
  
  A. Data identification
  1. Read and interpret health-record documentation to identify all diagnoses and procedures that affect the current inpatient stay/outpatient encounter visit.
  2. Assess the adequacy of health-record documentation to ensure that it supports all diagnoses and procedures to which codes are assigned.
  3. Apply knowledge of anatomy and physiology, clinical disease processes, pharmacology, and diagnostic and procedural terminology to assign accurate codes to diagnoses and procedures.
  4. Apply knowledge of disease processes and surgical procedures to assign non-indexed medical terms to the appropriate class in the classification/nomenclature system.
  
  
  B. Coding guidelines
  
  1. Apply knowledge of current approved "ICD-9-CM Coding and Reporting Official Guidelines" to assign and sequence the correct diagnosis and procedure codes for hospital inpatient services.
  2. Apply knowledge of current "Diagnostic Coding and Reporting Guidelines for Outpatient Services".
  3. Apply knowledge of CPT format, guidelines, and notes to locate the correct codes for all services and procedures performed during the encounter/visit and sequence them correctly.
  4. Apply knowledge of procedural terminology to recognize when an unlisted procedure code must be used in CPT.
  
  
  C. Regulatory guidelines
  1. Apply Uniform Hospital Discharge Data Set (UHDDS) definitions to select the principal diagnosis, principal procedure, complications and comorbid conditions, other diagnoses and significant procedures which require coding.
  2. Select the appropriate principal diagnosis for episodes of care in which determination of principal diagnosis is not clear because the patient has multiple problems.
  3. Apply knowledge of the Prospective Payment System to confirm DRG assignment which accurately reflects the occurrence of events and ensures appropriate reimbursement.
  4. Refuse to fraudulently maximize reimbursement by assigning codes that do not conform to approved coding principles/guidelines.
  5. Refuse to unfairly maximize reimbursement by unbundling services and codes that do not conform to basic coding principles and the National Correct Coding Initiative (CCI).
  6. Apply knowledge of the Ambulatory Surgery Center (ASC) Payment Groups to confirm ASC assignment which ensures appropriate reimbursement.
  7. Apply policies and procedures on health record documentation, coding, and claims processing and appeal. 8
  8. Use the HCFA Common Procedural Coding System (HCPCS) to appropriately assign HCPCS codes for outpatient Medicare reimbursement.
  
  
  D. Coding
  1. Exclude from coding those diagnoses, conditions, problems, and procedures related to an earlier episode of care which have no bearing on the current episode of care.
  2. Exclude from coding those ICD-9-CM nonsurgical, noninvasive procedures which carry no operative or anesthetic risk.
  3. Exclude from coding information such as symptoms or signs characteristic of the diagnosis, findings from diagnostic studies, or localized conditions, which have no bearing on the current management of the patient.
  4. Apply knowledge of ICD-9-CM instructional notations and conventions to locate and assign the correct diagnosis and procedural codes and sequence them correctly.
  5. Facilitate data retrieval by recognizing when more than one code is required to adequately classify a given condition.
  6. Exclude from coding those procedures which are component parts of an already assigned CPT procedure code.
  
  
  E. Data quality
  1. Clarify conflicting, ambiguous, or nonspecific information appearing in a health record by consulting the appropriate physician.
  2. Participate in quality assessment to ensure continuous improvement in ICD-9-CM and CPT coding and collection of quality health data.
  3. Demonstrate ability to recognize potential coding quality issues from an array of data.
  4. Apply policies and procedures on health-record documentation and coding that are consistent with official coding guidelines.
  5. Contribute to development of facility-specific coding policies and procedures.