Revised 08/2025

HIM 255 - Health Data Classification Systems II CPT (2 CR.)

Course Description

Focuses on procedure classification using Current Procedural Terminology (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

Required for the Medical Records Coder Career Studies Certificate and Health Information Management AAS, this course is designed to introduce students to the CPT classification system. The course also focuses on official coding guidelines, Content Management System (CMS) Compliance Plan, Correct Coding Initiative, coding resources (official publications and vendor supported publications), and ethical issues in coding and classification.

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, HIM 254 or permission of instructor. The course will be offered to any student who meets the prerequisites/co-requisites and is program placed in the Health Information Management (HIM) program.

 CDC program placed students only:

Prerequisites/corequisites for CDC students are ENG 111, HIM 111, HIM 141, HIM 250, HIM 110, HIM 199, HIM 254 or permission of instructor. The course will be offered to any student who meets the prerequisites/co-requisites and is program placed in the Clinical Data Coding (CDC) program.

Course Objectives

Upon successful completion of this course, the student will:

  • Apply the principles of coding health care data using CPT
  • Demonstrate appropriate application of CPT coding guidelines
  • Describe basic structure of Healthcare Common Procedure Coding System (HCPCS) system and weighted payment methodology
  • Identify concepts of bundling, starred procedures, and other key CPT coding conventions
  • Demonstrate competency in use of modifiers
  • Interpret clinical information from primary health records to identify all procedures
  • Evaluate conflicting and ambiguous clinical information and recommend corrective action with the health care provider
  • Demonstrate use of American Medical Associate (AMA) CPT Assistant as a coding resource
  • Employ basic knowledge of encoding
  • Describe an appropriate system to keep CPT codes updated
  • Discuss the issues of multiple procedure classification systems currently used in the USA
  • Demonstrate appropriate management of ethical issues that coders may encounter

Major Topics to Be Included

  • Introduction to coding using CPT and HCPCS
  • CPT format and conventions
  • CPT coding steps, medical record as source document, official coding guidelines
  • CPT basic coding guidelines
  • Introduction to encoders
  • Ethical issues in coding
  • Coding evaluation and management
  • Coding anesthesia and surgery
  • Coding radiology and pathology/laboratory
  • Coding medicine
  • Uses of modifiers