Revised 08/2025
HIM 254 - Advanced Coding and Reimbursement (3 CR.)
Course Description
Focuses on the applications and evaluation of advanced coding skills through practical exercises using actual healthcare data; while examining the components of DRGs, APCs and APGs and other prospective payment in the healthcare environment. Utilizes current coding standards in identifying payment methodologies, revenue cycle management and reimbursement. Lecture 3 hours.
General Course Purpose
The purpose of the course is to introduce new concepts and assist students in applying sound coding principles to the following topics:
- Quality of coded data
- Healthcare fraud and abuse
- Prospective payment systems
- Classification/language systems: ICD, ICD-10-CM/PCS, ICD-O, ICIDH, DSM, SNOMEDCT, Reed, UMLS and others.
- Current USA insurance/reimbursement systems
This course is a requirement of the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) which is the accrediting organization for degree-granting programs in health informatics and information management. The course will be offered to any student that meet the prerequisites and/or are enrolled in the Health Information Management (HIM) or Clinical Data Coding (CDC) programs.
Course Prerequisites/Corequisites
HIM program placed students only:
Prerequisites/corequisites for HIM AAS students are BIO 142, HIM 110, HIM 130, HIM 141, HIM 142, HIM 220, HIM 226, HIM 250, HIM 260, HIM 229, HIM 230, HIM 249, HIM 251, HIM 233, HIM 252 or permission of instructor.
CDC program placed students only:
Prerequisites/corequisites for CDC students are ENG 111, HIM 111, HIM 141, HIM 250, HIM 110, HIM 199 or permission of instructor.
Course Objectives
Upon completing the course, the student will be able to:
- Compare global healthcare delivery models and describe the structure and function of the U.S. healthcare system.
- Explain the relationship between health insurance, employment, and the U.S. healthcare business model.
- Differentiate major types of health insurance plans, including private, employer-based, individual, and managed care models.
- Describe key government-sponsored health programs and their impact on the U.S. healthcare system.
- Compare retrospective and prospective reimbursement methodologies and identify hybrid payment models.
- Analyze major Medicare payment systems including inpatient, skilled nursing facility, outpatient, and physician payment systems.
- Describe the full revenue cycle and identify strategies to support revenue integrity, charge capture, coding, and billing processes.
- Discuss compliance, audit functions, and legal considerations related to healthcare reimbursement and documentation.
- Apply concepts of utilization management, case management, and value-based care in the context of cost control and quality improvement.
- Demonstrate understanding of coding, documentation integrity, and data exchange as they relate to reimbursement and compliance.
Major Topics to Be Included
- U.S. Healthcare System and global comparisons
- Foundations of health insurance
- Managed care models
- Government-sponsored programs
- Healthcare reimbursement methodologies
- Medicare inpatient payment systems
- Post-acute and outpatient payment systems
- Revenue cycle management
- Coding, documentation, and compliance
- Legal and regulatory considerations
- Emerging trends in reimbursement