HIM-2160: CODING WITH ICD-10-CM

Transcription

1 HIM-2160: Coding with ICD-10-CM 1 HIM-2160: CODING WITH ICD-10-CM Cuyahoga Community College Viewing:HIM-2160 : Coding with ICD-10-CM Board of Trustees: May 2018 Academic Term: Fall 2018 Subject Code HIM - Health Information Management Course Number: 2160 Title: Coding with ICD-10-CM Catalog Description: Principles, theories, concepts and applications required to code diseases and procedures using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Classification System. Credit Hour(s): 2 Lecture Hour(s): 1 Lab Hour(s): 3 Requisites Prerequisite and Corequisite BIO-2341 Anatomy and Physiology II, and HIM-1301 Introduction to Health Information Management and departmental approval: Program Manager approval. I. ACADEMIC CREDIT Academic Credit According to the Ohio Department of Higher Education, one (1) semester hour of college credit will be awarded for each lecture hour. Students will be expected to work on out-of-class assignments on a regular basis which, over the length of the course, would normally average two hours of out-of-class study for each hour of formal class activity. For laboratory hours, one (1) credit shall be awarded for a minimum of three laboratory hours in a standard week for which little or no out-of-class study is required since three hours will be in the lab (i.e. Laboratory 03 hours). Whereas, one (1) credit shall be awarded for a minimum of two laboratory hours in a standard week, if supplemented by out-of-class assignments which would normally average one hour of out-of class study preparing for or following up the laboratory experience (i.e. Laboratory 02 hours). Credit is also awarded for other hours such as directed practice, practicum, cooperative work experience, and field experience. The number of hours required to receive credit is listed under Other Hours on the syllabus. The number of credit hours for lecture, lab and other hours are listed at the beginning of the syllabus. Make sure you can prioritize your time accordingly. Proper planning, prioritization and dedication will enhance your success in this course. The standard expectation for an online course is that you will spend 3 hours per week for each credit hour. II. ACCESSIBILITY STATEMENT If you need any special course adaptations or accommodations because of a documented disability, please notify your instructor within a reasonable length of time, preferably the first week of the term with formal notice of that need (i.e. an official letter from the Student Accessibility Services (SAS) office). Accommodations will not be made retroactively. For specific information pertaining to ADA accommodation, please contact your campus SAS office or visit online athttp:// Blackboard accessibility information is available athttp://access.blackboard.com. Eastern (216) Voice Metropolitan (216) Voice

2 2 HIM-2160: Coding with ICD-10-CM Western (216) Voice Westshore (216) Voice Brunswick (216) Voice Off-Site (216) Voice III. ATTENDANCE TRACKING Regular class attendance is expected. Tri-C is required by law to verify the enrollment of students who participate in federal Title IV student aid programs and/or who receive educational benefits through other funding sources. Eligibility for federal student financial aid is, in part, based on your enrollment status. Students who do not attend classes for the entire term are required to withdraw from the course(s). Additionally, students who withdraw from a course or stop attending class without officially withdrawing may be required to return all or a portion of the financial aid based on the date of last attendance. Students who do not attend the full session are responsible for withdrawing from the course(s). Tri-C is responsible for identifying students who have not attended a course, before financial aid funds can be applied to students accounts. Therefore, attendance will be recorded in the following ways: For in-person courses, students are required to attend the course by the 15th day of the semester, or equivalent for terms shorter than 5-weeks, to be considered attending. Students who have not met all attendance requirements for an in-person course, as described herein, within the first two weeks of the semester, or equivalent, will be considered not attending and will be reported for non-attendance and dropped from the course. For blended-learning courses, students are required to attend the course by the 15th day of the semester, or equivalent for terms shorter than 5-weeks, or submit an assignment, to be considered attending. Students who have not met all attendance requirements for a blended-learning courses, as described herein, within the first two weeks of the semester, or equivalent, will be considered not attending and will be reported for non-attendance and dropped from the course. For online courses, students are required to login in at least two (2) times per week and submit one (1) assignment per week for the first two (2) weeks of the semester, or equivalent to the 15th day of the term. Students who have not met all attendance requirements for an online course, as described herein, within the first two weeks of the semester, or equivalent, will be considered not attending and will be reported for non-attendance and dropped from the course. At the conclusion of the first two weeks of a semester, or equivalent, instructors report any registered students who have Never Attended a course. Those students will be administratively withdrawn from that course. However, after the time period in the previous paragraphs, if a student stops attending a class, wants or needs to withdraw, for any reason, it is the student's responsibility to take action to withdraw from the course. Students must complete and submit the appropriate Tri-C form by the established withdrawal deadline. Tri-C is required to ensure that students receive financial aid only for courses that they attend and complete. Students reported for not attending at least one of their registered courses will have all financial aid funds held until confirmation of attendance in registered courses has been verified. Students who fail to complete at least one course may be required to repay all or a portion of their federal financial aid funds and may be ineligible to receive future federal financial aid awards. Students who withdraw from classes prior to completing more than 60 percent of their enrolled class time may be subject to the required federal refund policy. If illness or emergency should necessitate a brief absence from class, students should confer with instructors upon their return. Students having problems with class work because of a prolonged absence should confer with the instructor or a counselor. IV. CONCEALED CARRY STATEMENT College policy prohibits the possession of weapons on college property by students, faculty and staff, unless specifically approved in advance as a job-related requirement (i.e., Tri-C campus police officers) or, in accordance with Ohio law, secured in a parked vehicle in a designated parking area only by an individual in possession of a valid conceal carry permit. As a Tri-C student, your behavior on campus must comply with the student code of conduct which is available on page 29 within the Tri-C student handbook, available athttp:// must also comply with the College s Zero Tolerance for Violence on College Property available athttp:// documents/ zero-tolerance-for-violence-policy.pdf Outcomes Recognize and define various healthcare coding professions. 1. Discuss the history of the development of clinical vocabularies. 2. Discuss and understand various coding professions. 3. Discuss the standards mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Illustrate the principles of ICD-10-CM coding.

3 HIM-2160: Coding with ICD-10-CM 3 1. List and identify the chapters in ICD-10-CM. 2. List the chapter titles. 3. Identify the codes that correspond to the demographic chapters. 4. Discuss and apply ICD-10-Clinical Modification conventions. 5. Recognize the importance of the medical record as a source document. Determine and select appropriate conventions used in ICD-10-CM. 1. Differentiate among abbreviations, symbols, and instructional notes. 2. Identify the difference between type 1 and type 2 Excludes notes. 3. Define the abbreviations NOS (not otherwise specified) and NEC (not elsewhere classifiable). 4. Explain the purpose of the ICD-10-CM Official Guidelines for Coding and Reporting. 5. Describe the conventions used in ICD-10-CM. Identify steps in the diagnostic code selection. 1. Describe the medical documentation that must be present to select an ICD-10-CM code. 2. Identify the ICD-10-CM Official Guidelines for Coding and Reporting that impact the steps a coder follows when selecting diagnostic codes. 3. Identify and select main terms that are referenced in the Alphabetic Index of ICD-10-CM. 4. Summarize the steps in coding. 5. Explain key terms in diagnostic code selection: granularity and laterality. 6. Explain single-code, combination-code, and dual-code assignment. Recognize and apply the official diagnostic coding guidelines. 1. List the Cooperating Parties for ICD-10-CM. 2. Explain the purpose of the ICD-10-CM Official Guidelines for Coding and Reporting. 3. Identify the four sections of the ICD-10-CM Official Guidelines for Coding and Reporting. 4. Differentiate and explain the guidelines for inpatient versus outpatient and physician office visits. 5. Summarize the guidelines for sequencing and diagnostic codes: 1) selection of principal diagnosis and 2) reporting additional diagnosis. 6. Define key terms related to diagnostic coding guidelines: combination code, late effect, principal diagnosis, and secondary diagnosis. 7. Select and code diagnoses from case studies. Methods of Evaluation: 1. Homework assignments a. Responses to homework questions b. identifying correct ICD-10 diagnosis codes c. Discussion board participation d. Reading and writing review papers e. Reading textbook f. Reading legal articles g. Reading logs or forums h. Internet Research & Research paper 2. Quizzes and Tests 3. Midterm examination 4. Final examination 5. Student Participation and Interaction

4 4 HIM-2160: Coding with ICD-10-CM Course Content Outline: 1. Introduction to coding and coding professions a. History of the development of clinical vocabularies b. Coding professions c. Health Insurance Portability and Accountability Act of 1996 (HIPAA) standards 2. An over view of ICD-10-CM a. Chapters i. Titles ii. Correspond codes b. ICD-10-Clinical Modification conventions c. Medical record as a source document 3. Conventions used in ICD-10-CM a. Description of conventions b. Abbreviations i. NOS ii. NEC c. Symbols d. Instructional notes e. Type 1 and type 2 Excludes notes 4. Steps in diagnostic code selection a. Required edical documentation to select an ICD-10-CM code b. Steps to select diagnostic codes based on ICD-10-CM Official Guidelines for Coding and Reporting c. Main terms that are referenced in the Alphabetic Index of ICD-10-CM d. Steps in coding e. Key terms in diagnostic code selection i. granularity ii. laterality 5. Diagnostic coding guidelines a. Cooperating parties for ICD-10-CM b. Purpose of the ICD-10-CM Official Guidelines for Coding and Reporting c. Four sections of the ICD-10-CM Official Guidelines for Coding and Reporting d. Guidelines for inpatient versus outpatient and physician office visits e. Guidelines for sequencing and diagnostic codes i. Selection of principal diagnosis ii. Reporting additional diagnoses f. Key terms related to diagnostic coding guidelines i. Combination code ii. Late effect iii. Principal diagnosis iv. Secondary diagnosis 6. Infectious and parasitic diseases a. Key terms in the infectious and parasitic diseases section b. Differentiating between infectious and parasitic diseases c. Single-code, combination-code, and dual-code assignment d. Coding of symptomatic and asymptomatic causes of HIV e. Types of hepatitis and the code for each f. Infectious and parasitic disease codes using the ICD-10-CM system g. Case studies 7. Neoplasms a. Groups of neoplasms classified in ICD-10-CM b. Coding guidelines that relate to neoplasms c. Comparison of the ICD-9-CM and the ICD-10-CM code systems d. Key terms related to neoplasms 8. Diseases of the blood and blood-forming organs a. Three types of blood cells b. Diseases of the blood and blood-forming organs c. Codes for diseases of the blood and blood-forming organs

5 9. Endocrine, nutritional, and metabolic diseases a. Influence of hormones on functions within the body b. Different types of diabetes c. Selecting ICD-10-CM codes for the various types of diabetes d. ICD-10-CM coding guidelines for diabetes and endocrine, nutritional and metabolic diseases 10. Mental and behavioral disorders a. Mental health disorders and conditions and key terms related to these disorders b. Sequencing of codes for drug and alcohol abuse and dependence c. Coding for this specialty vs. coding from the other specialties d. Challenges of coding for this specialty e. Comparison of the ICD-9-CM and the ICD-10-CM coding systems for these disorders 11. Diseases of the nervous system a. Major structures of the nervous system b. Conditions that involve the nervous system c. Case studies 12. Disorders of the eye and adnexa a. Major structures of the eye and adnexa b. Disorders that impact the eye and adnexa c. Coding disorders of the eye and adnexa 13. Diseases of the ear and mastoid process a. Major structures of the ear and mastoid process b. Anatomy of the ear c. Coding disorders of the ear and mastoid process 14. Diseases of the circulatory system a. Diseases of the circulatory system b. ICD-10-CM guidelines for diseases of the circulatory system c. Types of hypertension and the codes for each d. Coding diseases of the circulatory system e. Key terms related to the circulatory system 15. Diseases of the respiratory system a. Major structures of the respiratory system b. Diseases and conditions that impact the respiratory system c. Terminology associated with the respiratory system d. Coding guidelines for diseases of the respiratory system e. Diagnostic codes for conditions and diseases of the respiratory system 16. Diseases of the digestive system a. Anatomical structures of the digestive system b. Conditions that are related to the digestive system c. Coding related to the different conditions encountered in the digestive system d. Diagnostic codes to diagnoses for the digestive system 17. Diseases of the skin and subcutaneous tissue a. Layers of the skin b. Conditions and diagnoses related to the skin and subcutaneous tissue c. Coding diagnoses of diseases of the skin and subcutaneous tissue 18. Diseases of the musculoskeletal system and connective tissue a. Identify the anatomical structures of the musculoskeletal system b. Explain the conditions and disorders that affect the musculoskeletal system c. Coding guidelines related to the conditions encountered in the muskuloskeletal system d. Coding guidelines for coding acute fractures versus aftercare HIM-2160: Coding with ICD-10-CM 5

6 6 HIM-2160: Coding with ICD-10-CM 19. Diseases of the genitourinary system a. Anatomical structures of the urinary system b. Anatomical structures of the male and female genital tracts c. Conditions related to the genitourinary system d. Coding guidelines related to the conditions encountered in the genitourinary system 20. Pregnancy, childbirth, and the puerperium a. Stages of pregnancy b. Complications encountered during pregnancy and how they affect code assignment c. Coding guidelines related to the coding of this section d. Use of the final character indicating the code for trimester of pregnancy e. Different types of abortions and explain how the code assignments are affected 21. Conditions originating in the perinatal period a. Perinatal conditions of the mother affecting the fetus or newborn b. Conditions that may affect the fetus or newborn c. Perinatal conditions 22. Congenital malformations, deformations, and chromosomal abnormalities a. Difference between the terms congenital anomaly and deformity b. Conditions related to this section c. Congenital vs. acquired conditions 23. Symptoms, signs, and abnormal clinical laboratory findings a. Terms used in locating codes for symptoms, signs, and ill-defined conditions b. Coding guidelines that relate to "Symptoms, Signs, and Abnormal Clinical Laboratory Findings Not Elsewhere Classified" c. Code signs, symptoms, and ill-defined conditions from cases studies 24. Injury, poisoning, and certain other consequences of external causes a. Combination codes for injuries b. Various types of fractures c. Abrasions, contusions, and superficial and complex injuries d. Types of open wounds e. Coding guidelines that relate to injuries and poisoning 25. External causes of morbidity a. What "external cause" means and when it is appropriately assigned b. Sequencing of the V, W, X and Y codes c. Case studies 26. Factors influencing health status and contact with health services a. Purpose of Z codes and identify key terms used to locate Z codes b. Encounters for which Z codes are used c. V codes in ICD-9-CM vs. Z codes in ICD-10-CM.. Resources Venes, Donald, ed. (2016)Taber's Cyclopedic Medical Dictionary,Philadelphia: Davis. (2018)ICD-10-CM Code Books,Ingenix, IL. Sayles, Nanette. (2016)Health Information Management Technology an Applied Approach,Chicago, IL: American Health Information Management Association. Bowie, Mary Jo., and Schaffer, Regina. (2017)Understanding ICD-10-CM and ICD-10-PCS, a Worktext,Clifton Park: Delmar.

7 HIM-2160: Coding with ICD-10-CM 7 Smith, Gail. (2011)2011 ICD-10-CM and ICD-10-PCS Workbook,Clifton Park: Delmar. Resources Other 1. Journal of the AHIMA/American Health Information Management Association,Chicago, IL: The Association,Monthly publication. 2. 3M Clinical Coding Encoder Software 3. Internet searches for diagnostic conditions Top of page Key: 2163