MCCCD Official Course Competencies:

HIM211  2006 Fall – 2009 Summer II

Advanced Applications of Coding and Reimbursement

1.

Use a variety of references to assist in research for accurate code assignment. (I)

2.

Differentiate among various prospective payment systems. (II)

3.

Describe the relevance and appropriate use of complications and comorbidities (CCs) in Diagnostic Related Group (DRG) assignment. (III)

4.

Identify appropriate code sets and describe coding guidelines used in a variety of health care settings. (III-IX)

5.

Assign appropriate International Classification of Diseases (ICD) diagnosis and procedure codes in a variety of health care settings. (III-IX)

6.

Compare various coding, abstracting, and reporting software programs for code and DRG assignment. (III)

7.

Appropriately use software programs for code and DRG assignment. (III)

8.

Use DRG, case mix, severity of illness, report evaluation, and case selection findings for administrative reporting. (III, X)

9.

Assign codes using other classification systems including the Diagnostic and Statistical Manual (DSM), International Classification of Diseases - Oncology (ICD-O), and Systematized Nomenclature of Medicine (SNOMED). (VII-IX)

10.

Evaluate codes for accuracy and completeness and reconcile codes with documentation. (X)

11.

Participate in revenue cycle/reimbursement monitoring and chargemaster maintenance. (X)

12.

Describe the role of local medical review policies (LMRP), local medical determination (LMD), and peer review groups in reimbursement management. (X)

13.

Describe components of a coding compliance program. (X)

MCCCD Official Course Outline:

HIM211  2006 Fall – 2009 Summer II

Advanced Applications of Coding and Reimbursement

I. Coding References Update

A. Pharmaceuticals

B. Disease processes

C. New procedures

D. Terminology and acronyms

E. Regulations

II. Prospective Payment Systems

A. Background

B. Regulations

C. Current systems

1. Hospital inpatient

2. Skilled nursing facility (SNF)

3. Home health agency

4. Rehabilitation hospital

5. Other

III. Hospital Inpatient Diagnostic Related Groups (DRGs)

A. Definitions and organization

B. Case mix and severity of illness

C. Application of coding guidelines

D. Encoder, grouper, and other software programs

E. Complications and comorbidities

F. Abstracting

IV. SNF Resource Utilization Groups (RUGs)

A. Definitions and organization

B. Data reporting systems

C. Coding guidelines and application

V. Home Health Resource Groups (HHRG)

A. Definitions and organization

B. Data reporting systems

C. Coding guidelines and application

VI. Rehabilitation Hospital Case Mix Groups (CMGs)

A. Definitions and organization

B. Data reporting systems

C. Coding guidelines and application

VII. Psychiatric Care Code Sets

A. Definitions and organization

B. Data reporting systems

C. Diagnostic and Statistical Manual (DSM) coding guidelines and application

VIII. Oncology Code Sets

A. Definitions and organization

B. Data reporting systems

C. International Classification of Diseases-Oncology (ICD-O) coding guidelines and application

D. Tumor Registry

IX. Other Settings and Code Sets

X. Administrative Functions

A. Quality management

1. Monitoring

2. Data compilation

3. Reporting

4. Data analysis

B. Reimbursement management

1. Revenue cycle monitoring

2. Chargemaster maintenance

3. External groups and policies

C. Compliance programs

1. Structure

2. Application