Health Information Technology
Intermediate ICD-9-CM Coding
This course is designed to prepare a student to code in the hospital setting using ICD-9-CM. The course will emphasize reporting requirements for codes and rules that apply to reimbursement systems used by government payers and other health plans. The student will be introduced to computerized coding systems utilized in healthcare. The emphasis of the course will be development of intermediate skills to code accurately and ethically. Students will assign codes for diagnoses, services and procedures that are documented in the health/medical record. This course is the theory and practice of coding medical records in the hospital setting using ICD-9-CM. The student will use the encoding software in the laboratory to apply coding to charts.
(A requirement that must be completed before taking this course.)
Upon successful completion of the course, the student should be able to:
- Conduct analysis to ensure documentation in the health record supports the diagnosis and reflects the patient's progress, clinical findings and discharge status.
- Describe the process to clarify conflicting, nonspecific information appearing in the health/medical record.
- Apply diagnosis/procedure codes using ICD-9-CM.
- Use and maintain electronic applications and work processes to support clinical classification and coding.
- Ensure accuracy of diagnostic/procedural groupings to confirm Medicare Severity Diagnosis Related Groups (MS-DRG) assignment.
- Adhere to current regulations and established guidelines in code assignment.
- Validate coding accuracy using clinical information found in the health record.
- Use and maintain applications and processes to support other clinical classification and nomenclature systems (such as ICD-10-CM, SNOMED and so on).
- Monitor coding and revenue cycle processes including case mix index.
- Resolve discrepancies between coded data and supporting documentation.
- Explore the certification process of the American Health Information Management Association (AHIMA).
- Apply Present on Admission (POA) indicator guidelines.
- Utilize coding references such as "Coding Clinic" to clarify current coding issues.
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