HIM 3020 - Inpatient Coding and Billing

1. Define terms, phrases, abbreviations, and acronyms related to:

a. history and evolution of hospitals.

b. the hospital regulatory environment, federal and state regulations, accreditation, and nonclinical credentials.

c. hospital functions and departments.

d. patient accounts and data flow.

e. the hospital billing and claims process.

f. patient account transactions and accounts receivable follow-up.

g. coding conditions for hospital services.

h. coding procedures rendered during hospital visits.

i. coding guidelines and applications.

j. claim forms.

k. third party payers.

l. government-sponsored health insurance.

m. Prospective Payment Systems.

n. HIPAA regulations and compliance.

2. Demonstrate an understanding of how hospitals evolved from ancient times to today.

a. Understand the influence of advances made in medicine on hospital evolution.

3. Be able to discuss three areas of economic influence on hospital development.

a. Describe how changes in reimbursement systems affected hospital development.

b. Discuss the difference between a primary care network and an integrated delivery system.

4. Explain the purpose of a hospital.

a. Differentiate among diagnostic, therapeutic, palliative, and preventive services.

b. Describe three levels of care provided at hospitals.

c. Provide an explanation of the difference between a for-profit and a not-for-profit hospital.

d. Demonstrate an understanding of different types of hospitals.

5. Describe factors that led to the government’s expanded role in regulating health care.

a. Demonstrate an understanding of federal and state legislation implemented to address health care issues and the impact of the legislation on the hospital’s regulatory environment.

b. Discuss how the creation of Medicare and Medicaid enhanced the government’s role in health care regulation.

c. Provide a brief overview of federal and state regulatory agencies involved in health care regulation.

d. Demonstrate an understanding of state licensing requirements and how they have an impact on the hospital’s structure and function.

6. State the purpose of accreditation and explain why it is important.

a. Provide an overview of the history of accreditation.

b. Demonstrate an understanding of accreditation organizations and the survey process.

c. Explain the relationship between federal and state regulations and accreditation.

d. Discuss various credentials required for hospital billing and coding personnel.

e. Define terms, phrases, abbreviations, and acronyms related 

7. Understand hospital organizational structures and how they are designed to contribute to the accomplishment of a hospital’s goals and mission.

a. Explain how organizational structures may vary.

8. List and describe four categories of functions in a hospital.

a. Describe functions performed by various departments.

9. Understand the importance of the Compliance Department in a hospital.

10. Provide an explanation of how financial departments contribute to maintaining the financial stability of a hospital.

11. Discuss the relationship among the Health Information Management Department, medical record documentation, and submission of charges.

a. Explain the purpose of medical record documentation and what significant information is maintained in the medical record.

12. Identify and discuss three service levels where patient care services are rendered in a hospital.

13. Demonstrate an understanding of patient accounts and data flow for outpatient, ambulatory surgery, and inpatient services.

a. Define patient admission and discuss procedures required to ensure quality of patient care.

b. Outline the patient care process and provide an explanation of each phase.

c. Demonstrate an understanding of the admission process and forms utilized during the process.

d. Provide an explanation of the insurance verifications process.

e. Describe the relationship between the admission process and billing of patient services.

14. Discuss the purpose of medical record documentation and various forms and documents used in the medical record.

15. Demonstrate an understanding of patient care services provided by a hospital.

16. Provide an explanation of how charges are captured in the hospital.

17. State the role of Health Information Management (HIM) in billing patient services.

a. Demonstrate an understanding of the hospital billing process, including denied, pended, and paid claims, and posting patient transactions.

b. Demonstrate an understanding of the importance of accounts receivable (A/R) management and reports utilized.

18. Demonstrate an understanding of the billing process and its purpose.

19. Discuss the relationship among participating provider agreements, claim forms, reimbursement methods, and the billing process.

20. Explain the significance of submitting a clean claim.

a. Demonstrate understanding of the variations in claim requirements by payer types and type of service.

b. Explain the purpose of the charge master and its relationship to billing.

c. List and explain data elements in the charge master and discuss maintenance of the charge master.

d. Provide an overview of categories of services and items billed by the hospital.

21. Differentiate between coding systems utilized for outpatient services versus those used for inpatient services.

22. Discuss the purpose of the detailed itemized statement.

23. Discuss the purpose of a claim form and provide a brief outline of information recorded on a claim form.

24. Demonstrate an understanding of all elements and phases in the hospital billing process.

25. Demonstrate an understanding and explain the significance of A/R management.

a. Provide an overview of the purpose and function of an accounts receivable report.

b. Explain why a claim would not meet clean claim status.

c. List common reasons for claim denials and delays.

d. Describe the process of monitoring and follow-up of outstanding claims.

e. Demonstrate an understanding of the appeals process

26. Demonstrate an understanding of the life cycle of a hospital claim.

a. Understand the elements related to patient transactions.

27. Provide an overview of key information found on an Explanation of Benefits or remittance advice.

28. Demonstrate an understanding of the history and purpose of diagnosis coding.

29. Understand how ICD-9-CM coding data are utilized for research, education, and administrative purposes.

30. Provide an explanation of the relationship among documentation, medical necessity claim forms, reimbursement, and coding.

31. Outline the content of ICD-9-CM Volume I and II.

a. Demonstrate an understanding of ICD-9-CM coding conventions.

b. Demonstrate an understanding of ICD-9-CM coding principles.

c. Demonstrate an understanding of coding utilizing the ICD-9-CM diagnosis coding system.

32. Demonstrate an understanding of the history and purpose of procedure coding systems.

33. Discuss how procedure coding data are utilized for research, education, and administrative purposes.

34. Demonstrate an understanding of coding utilizing the HCPCS and ICD-9-CM Volume III procedure coding systems.

a. Explain the two levels of HCPCS.

b. Provide an explanation of the relationship among procedure coding and documentation, medical necessity, claim forms, and reimbursement.

35. List the content of the CPT coding system.

36. Outline the content of the ICD-9-CM Volume III coding system.

37. Demonstrate an understanding of the steps to coding.

a. Discuss the relationship between procedure coding and diagnosis coding.

b. Demonstrate an understanding of coding principles.

38. Explain the relationship between billing and coding.

39. Discuss variations in coding systems utilized for inpatient and outpatient services.

40. Provide an outline of the basic steps to abstracting from the medical record.

a. Apply coding guidelines for inpatient and outpatient cases.

b. Demonstrate an understanding of coding principles and guidelines.

41. Explain the purpose of claim forms.

42. Describe manual and electronic claim submission and discuss advantages and disadvantages of each submission method.

43. Explain the difference between the CMS-1500 and CMS-1450 (UB-04) and outline when they are used.

a. Discuss variations in claim form usage and coding systems utilized for each of the claim forms.

b. Demonstrate an understanding of data requirements and completion instructions of the CMS-1500 and CMS-1450 (UB-04).

44. Explain the relationship between third-party payers and private health insurance.

45. Distinguish among different insurance plans.

a. List other types of insurance that provide coverage for health care services.

b. Demonstrate an understanding of basic terms and specifications found in insurance plans.

46. Define managed care.

a. Discuss the differences between traditional fee-for-service and managed care plans.

47. Provide an overview of coverage for each government program.

a. Understand the relationship between third-party payers and government programs.

b. Distinguish between traditional government plans and managed care plans.

c. State primary versus secondary responsibility for Medicare, Medicaid, and TRICARE.

48. Demonstrate an understanding of basic terms and specifications.

49. Explain why government programs implemented managed care plans.

a. Describe the role of the Centers for Medicare and Medicaid Services (CMS) in government plans.

b. Provide a brief overview of eligibility requirements for each government program.

50. Demonstrate an understanding of the evolution of health care reimbursement from cost-based systems to Prospective Payment Systems.

51. Describe the relationship between government programs and Prospective Payment Systems.

a. Discuss various payment systems implemented under the Prospective Payment System.

b. Demonstrate an understanding of Inpatient Prospective Payment Systems (IPPS) development, payment calculations, structure and assignment.

c. Provide an overview of the Prospective Payment Systems used to reimburse hospitals for inpatient and outpatients services.

d. Demonstrate an understanding of Outpatient Prospective Payment System (OPPS) development, payment calculations, structure, and assignment.

e. Explain what coding systems are used to submit charges under Prospective Payment Systems, and how they affect reimbursement.

52. Describe two major issues facing the health care industry leading to the implementation of HIPAA.

53. Demonstrate an understanding of the purpose and content of HIPAA regulations.

a. Explain the relationship between HIPAA privacy regulations and the patient’s medical information.

54. Demonstrate an understanding of the Administrative Simplification section of HIPAA and how it relates to claims processing.

a. Describe provisions outlined under the Administrative Simplification section of HIPAA

55. Discuss provisions outlined under the Privacy section of HIPAA

a. Demonstrate an understanding of the HIPAA Privacy Rule and how it relates to patient medical information.

56. Discuss provisions outlined under the HIPAA Security Rule.

57. Discuss the importance of HIPAA Compliance.

58. Provide an overview of the elements of a compliance plan.