HIM 2030 - Intro to Medical Coding
Clock Hours: 120
Delivery Mode
on-ground
Course Description:
This course focuses on learning the coding rules for the CPT, ICH-10-CM, HCPCS, and ICD-10-PCS coding systems and applying the rules to code patient services.
Student Learning Outcomes:
Course Competencies:
1. Understand the problems with paper based medical record systems.
2. Understand how electronic medical records, electronic health records, and personal health records differ.
3. Describe the core functions of an electronic health record.
4. Understand how electronic health records reduce medical errors, increase the quality of care, and bring down health care costs.
5. Understand why electronic health records are important to health care reform.
6. Describe the major strategies for converting paper based records to EHR.
a. Identify the ways of entering live data into an EHR.
b. Explain the differences in the various EHR models.
c. Explain the importance of adopting clinical standards.
7. Describe the clinical vocabularies and classification systems.
8. Understand how computers share information.
9. Understand the ways EHR enhances each step of the office visit.
a. List the five steps of the office visit workflow in a physician office.
b. Describe the advantages of pre-visit scheduling and information scheduling.
c. Describe the process of electronic check-in.
d. Explain how electronic health records make documenting patient exams more efficient.
e. Explain what happens during patient checkout.
f. Explain the two events that take place during the post-visit step of the visit workflow.
10. Describe the advantages of computer assisted coding.
11. Understand how clinical tools assist physicians in making medical decisions and managing patients with chronic diseases.
a. Describe the support tools available with an EHR.
b. Explain the safety checks that an EHR’s e-0prescribing feature can perform when a physician selects a new medication for a patient.
c. Understand how EHR tools monitor patients’ compliance with recommended wellness guidelines.
12. Understand the advantages of electronic health records in a hospital.
a. Understand the role of documentation in quality improvement efforts.
b. Understand how CPOE reduces medication errors.
c. Understand how eMAR systems are used to check the five rights when administering medication to a patient
13. Understand why personal health records are becoming important to individuals in managing their own health care.
a. Understand the ways in which personal health records are more than storehouses for health records.
b. Understand the advantages and disadvantages of the different categories of personal health records.
c. Understand the barriers to the implementation of personal health records.
14. Understand the importance of the HIPAA Privacy Rule to the protection of personal health information.
a. Understand when PHI can be released with a patient’s consent and when an authorization must be obtained.
15. Understand how the increasing use of computers and networks place health information at risk.
16. Understand the types of safeguards included in the HIPAA Security Rule.
17. Explain how the use of access levels protects the privacy of a patient’s PHI.
18. Describe the purpose of the dashboard.
19. Explain where patient registration information is stored and accessed.
20. Explain the function of the Chart Summary.
21. Describe how progress notes can be entered.
22. List the safety and cost control features of an electronic order entry.
23. Explain how to understand normal and abnormal values in vital signs and lab results.
24. Understand how to enter information in an EHR program through hands on experience.
25. Understand how to locate information in an EHR program through hands on experience.
26. Understand how to review information in an EHR program through hands on experience.
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