Health Insurance Billing and Coding
I. BASIC COURSE INFORMATION
- Course Title:
Health Insurance Billing and Coding
- Course Number:
- Course Name:
Electronic Health Records
- Credit Hours:
- Semesters Offered:
EHR 110, EHR 210
II. COURSE DESCRIPTION
This course provides students with information about major insurance programs and federal healthcare legislation. Students will also gain a basic knowledge of national diagnosis and procedure coding systems. Topics include: aspects of medical insurance, plan options, payer requirements, state and federal regulations, abstracting of source documents, accurate completion of claims, and coding of diagnoses and procedures/services.
III. RATIONALE OF COURSE
Accurate processing of healthcare claims has become more exacting and rigorous as health insurance plan options have rapidly expanded. These changes, combined with modifications in state and federal regulations affecting the health insurance industry, are a constant challenge to healthcare providers. This course will provide students with the knowledge and skills necessary to meet these challenges.
IV. COURSE COMPETENCIES
Upon completion of this course, the student will be able to:
- Define terminology related to health insurance.
- State the difference between medical care and healthcare.
- Define health insurance.
- List and describe the purposes for medical documentation.
- Describe the advantages of implementing electronic health records.
- Define terminology related to managed healthcare.
- Explain the role of a managed-care organization.
- Identify common managed-care models and interpret the services they provide.
- Describe the benefits of a consumer-directed health plan.
- Describe the effects of managed-care on a physician's practice.
- Define terminology related to processing an insurance claim.
- Demonstrate processing of an insurance claim using Medical Office Simulation Software (MOSS).
- Explain how claims processing for new and established patients differ.
- List and describe the four stages of the insurance claim life cycle including Electronic Data Interchange (EDI).
- List and describe four types of claims and files that can be securely stored as electronic claims files.
- Explain how unpaid claims are tracked.
- Explain the role of credit and collections in processing claims.
- Define terminology related to International Classification of Diseases-9th Revision-Clinical Modification (ICD-9-CM) coding.
- Explain the concept of medical necessity as it relates to reporting diagnosis codes on claims.
- Interpret ICD-9-CM coding guidelines.
- Identify and properly use ICD-9-CM coding conventions.
- Accurately code diagnoses according to ICD-9-CM.
- Define terminology related to International Classification of Diseases-10th Revision-Clinical Modification (ICD-10-CM) coding.
- Use ICD-9-CM as a legacy coding system and interpret general equivalency mappings.
- Describe the purpose and use of the ICD-10-CM and ICD-10-Procedure Classification System (PCS) coding systems.
- Interpret ICD-10-CM coding conventions to accurately assign codes.
- Interpret diagnostic coding and reporting guidelines.
- Accurately code diagnoses according to ICD-10-CM.
- Define terminology related to Current Procedural Terminology (CPT) coding.
- Explain the format used in CPT.
- Locate main terms and sub terms in the CPT index.
- Select appropriate modifiers to add to CPT codes.
- Assign CPT codes to procedures and services.
- Define terminology related to Healthcare Common Procedure Coding System (HCPCS).
- List and describe HCPCS levels.
- Assign HCPCS Level II codes and modifiers.
- Recognize patient record documentation necessary in completing a Certificate of Medical Necessity.
- Define terminology related to Centers for Medicare and Medicaid Services (CMS) reimbursement methodologies.
- Interpret various fee schedules and state their applications.
- Interpret a charge master and explain the information posted to the patient's bill.
- Demonstrate completion of a UB04 claim form using MOSS.
- Define terminology related to coding for medical necessity.
- Select and code diagnoses and procedures from case studies and sample reports.
- Define terminology related to Blue Cross Blue Shield (BCBS).
- Identify coverage included under BCBS plans.
- Explain the importance of providing information in all required fields and proper locations on the health insurance claim form CMS-1500 (Blue Cross Blue Shield, Medicare, Medicaid and Workers' Compensation.
- Define terminology related to Workers' Compensation.
- Describe the eligibility requirements for Workers' Compensation coverage.
- Interpret various classifications of Workers' Compensation cases.
- Explain the importance of providing information in all required fields and proper locations on the Workers' Compensation First Report of Injury form.
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