COURSE DESCRIPTION

Focuses on procedure classification using CPT. This system is currently utilized for collecting health data for the purposes of statistical research and financial reporting. Lecture 2 hours per week.

GENERAL COURSE PURPOSE

This course is designed to introduce the student to the CPT classification system. Attention also focuses on official coding guidelines, CMS Compliance Plan, Correct Coding Initiative, coding resources (official publications and vendor supported publications), and ethical issues in coding and classification.

ENTRY LEVEL COMPETENCIES

Program placement in Health Information Technology degree program or Clinical Data Coding career studies program or permission of the instructor. Prerequisites are HIT 110 and HIT 111 plus either BIO 141/142 or NAS 150 or permission of the instructor. May be currently enrolled in HIT 110, BIO 142 and/or NAS 150.

COURSE OBJECTIVES

Upon successful completion of this course, the student will:

A. Apply the principles of coding healthcare data using CPT

B. Understand appropriate application of CPT coding guidelines

C. Describe basic structure of HCPCS system and weighted payment methodology

D. Identify concepts of bundling, starred procedures and other key CPT coding conventions

E. Develop basic competency in use of modifiers

F. Read and interpret clinical information from primary health records to identify all procedures

G. Learn to clarify conflicting/ambiguous clinical information with the responsible healthcare provider

H. Demonstrate use of AMA’s CPT Assistant as a coding resource

 I. Demonstrate basic knowledge of encoders

 J. Describe system to keep CPT updated

K. Discuss the issues of multiple procedure classification systems currently used in USA

L. Demonstrate appropriate handling of ethical issues that coders may encounter

Major topics of this course are:

A. Introduction to coding using CPT and HCPCS

B. CPT format and conventions

C. CPT coding steps, medical record as source document, official coding guidelines

D. CPT basic coding guidelines

E. Introduction to encoders

F. Ethical issues in coding

G. Coding evaluation and management

H. Coding anesthesia and surgery

 I. Coding radiology and pathology/laboratory

 J. Coding medicine

K. Uses of modifiers