NAHCE UNIVERSITY

Integrated Electronic Health Records Curriculum

Electronic Health Records

100: THE ELECTRONIC HEALTH RECORD

Learning Outcomes:

ER 100

1 Overview of the Electronic Health Record

2 History of the Electronic Health Record

3 EHR Terminology

4 Government Involvement in the EHR

5 Healthcare Processes and the EHR

6 Barriers and Benefits of the EHR

7 The Future of the Electronic Health Record

110: STANDARDS AND FEATURES OF ELECTRONIC HEALTH

Learning Outcomes:

ER 100

1 History of EHR Standards

2 EHR Functionality

3 privacy, and security of the EHR

4 EHR Implementation and Technology

5 Electronic Health Record Competencies

THE CLINIC ADMINISTRATION

Learning Outcomes:

ER 130

1 The Practice View Screen

2 Appointment Schedule

3 Patient Tracker

4 To Do Lists and Reminders

5 Internal Messages

6 Urgent Messages

THE PATIENT CHART

Learning Outcomes:

ER 140

1 Overview of the Patient Chart

2 Creating a Face Sheet

3 Procedures in a Patient’s Chart

4 New Activities in a Patient’s Chart

THE OFFICE VISIT

Learning Outcomes:

ER 150

1 Components of the Office Visit

2 Building an Office Visit Note

3 Activities within the Office Visit Screen

4 Routing Slip

5 Adding Addenda to an Office Visit Note

6 Office Visit Reports

CLINICAL TOOLS

Learning Outcomes:

ER 160

1 Chart Evaluation

2 Test Orders

3 Evaluation & Management Coder

4 Superbill Form

5 Patient Instructions

6 Care Plans and Practice Guidelines

7 Drawing Courses

8 Importing Documents

CREATING TEMPLATES

Learning Outcomes:

ER 170

1 Creating Office Visit Templates

2 Creating Physician Order Templates

3 Creating Letter Templates

4 Template Manager

5 Creating Procedure Templates

TESTS, PROCEDURES, AND CODES

Learning Outcomes:

ER 180

1 Ordering a Test

2 SpringLabs and Reference Lab Results

3 Processing and Charting Tests

4 Creating a Test Report

5 Documenting, Activating, and Editing Procedure Codes

6 Documenting, Activating, and Editing Diagnosis Codes

PRODUCTIVITY CENTER AND UTILITIES

Learning Outcomes:

ER 190

  1. Bulletin Board
  2.  Integrated Faxing
  3.  Time Clock
  4.  My Websites
  5.  Calculators
  6.  Patient Database Reporting
  7.  Patient Archive

JOINING YOUR KNOWLEDGE

Learning Outcomes:

ER 200

  1.  Practice View Screen
  2.  Patient Chart Screen
  3.  Office Visit Screen

Integrated Electronic Health Records

An Overview of PrimeSUITE’s Practice Management and Electronic Health Record Software

Learning Outcomes:

ER 205

Health Data Structure, Collection, and Standards

Learning Outcomes:

ER 215

  1. The Professionals Who Maintain and Use Health Information
  2. Data versus Information
  3. Computer-Based Health Information Media
  4. Screen-Based Data Collection Tools
  5. Collecting Data Elements
  6. Electronic Health (Medical) Records (EHR) (EMR)
  7. Laws, Regulations, and Standards
  8. Similarities and Differences between a Physician’s Office and Hospital Information
  9. Systems

Content of the Health Record—Administrative Data

Learning Outcomes:

ER 225

  1. Administrative Data Elements
  2. Administrative Uses of Data
  3. Accountable Care
  4. The Master Patient (Person) Index (MPI)
  5. Registering a New Patient in PrimeSUITE
  6. Scheduling an Appointment
  7. Editing Demographic Data
  8. Checking in a Patient
  9. Capture Insurance Information
  10. Utilize the Help Feature

Content of the Health Record—the Past Medical, Surgical, Family, and Social History

Learning Outcomes:

ER 235

  1. Forms as Data Collection Tools
  2. The Past Medical, Surgical, Family, and Social Histories
  3. Handling Inconsistent or Unclear Information
  4. Documenting Vital Signs

Content of the Health Record—the Care Provider’s Responsibility

Learning Outcomes:

ER 245

  1. The SOAP Note
  2. The History of Present Illness (HPI)
  3. The Review of Systems (ROS)
  4. The Physical Exam
  5. Medical Dictation and Transcription
  6. Voice (Speech) Recognition Technology
  7. Electronic Prescribing (ePrescribing)
  8. Computerized Physician Order Entry (CPOE)
  9. Tracking Physicians’ Orders
  10. The Problem List

Financial Management: Insurance and Billing Functions

Learning Outcomes:

ER 255

  1. Claims Management—Why and How
  2. Use of an Encounter Form
  3. The Claims Process Using PrimeSUITE
  4. Diagnosis and Procedure Coding Using PrimeSUITE
  5. The Relationship between Documentation and Coding
  6. Accountable Care Organizations
  7. Accounts Receivable—Getting Paid
  8. Managing Accounts Receivable in PrimeSUITE
  9. Compliance

Privacy, Security, Confidentiality, and Legal Issues

Learning Outcomes:

ER 265

  1. The HIPAA Privacy and Security Standards
  2. Evaluating an EHR System for HIPAA Compliance
  3. The Role of certificate in EHR Implementation
  4. Applying Security Measures
  5. Handling Sensitive and Restricted Access
  6. Data Integrity
  7. Apply Policies and Procedures to Release Health Information Using PrimeSUITE
  8. Accounting of Information Disclosures
  9. Information Exchange
  10. Compliance Plans
  11. Safeguarding Your System and Disaster Recovery Planning

Management of Information and Communication

Learning Outcomes:

ER 275

  1. Internal Communications
  2. Importing Documents to the EHR
  3. Master Files and Templates
  4. Customization
  5. Using Software to Organize Your Work—Task Lists
  6. Using Software as a Reminder

Decision and Compliance Support: Utilizing the Database

Learning Outcomes:

ER 285

  1. Using the Dashboard in PrimeSUITE to Meet Meaningful Use Standards
  2. Data and Information Used in Decision Support
  3. Use of Report-Writer for System Reports
  4. Custom Report Writing
  5. Uses of Indexes
  6. Uses of Registries
  7. The Credentialing Process

Procedure Coding

LEGAL AND ETHICAL ISSUES

Learning Outcomes:

PC 110

    • 1.1 Health Insurance Portability and Accountability Act
    • 1.2 Health Care Fraud and Abuse Control Program
    • 1.3 National Correct Coding Initiative 14 Federal False Claims Act
  • 1.4 Rules for Ethical and Legal Coding 14
  • 1.5 Codes of Ethics American Health Information Management Association Code of Ethics AAPC Code of Ethical Standards
  • 1.6 Compliance Programs

INTRODUCTION TO CODING AND CPT

Learning Outcomes:

PC 120

  • 2.1 Medical Necessity
  • 2.2 Procedures (Services and Treatments) Specific Code Definitions
  • 2.3 Seven Steps to Accurate Coding
  • 2.4 Coding from Physician’s Notes CPT Coding ebook The Organization of the CPT ebook CPT Resequencing Initiative
  • 2.5 Guidelines, Formats, and Notations
  • 2.6 Notations and Symbols Chapter Summary

INTRODUCTION TO CPT MODIFIERS

Learning Outcomes:

PC 130

  • 3.1 Procedure Code Modifiers CPT Code Modifiers
  • 3.2 Personnel Modifiers
  • 3.3 Anesthesia Physical Status Modifiers Ambulatory Surgery Center Hospital Outpatient Use Modifiers
  • 3.4 HCPCS/National Level II Modifiers
  • 3.5 Sequencing Multiple Modifiers Two or Three Modifiers Needed More Than Three Modifiers Needed
  • 3.6 Supplemental Reports Chapter Summary

EVALUATION AND MANAGEMENT CODES, PART 1

Learning Outcomes:

PC 140

  • 4.1 location
  • 4.2 Relationship Key Components
  • 4.3 Level of Service Counseling Face-to-Face (Office and Other Outpatient Visits) Unit/Floor Time (Hospital and Other Inpatient Visits) Non–Face-to-Face
  • 4.4 Prolonged Services: 99354–99359
  • 4.5 Consultations
  • 4.6 Reading the Physician’s Notes

EVALUATION AND MANAGEMENT CODES, PART 2

Learning Outcomes:

PC 150

  • 5.1 Preventive Medicine Counseling and/or Risk Factor Reduction Intervention
  • 5.2 long-Term Care Services Care Plan Oversight Services Admission to the Nurse Facility: 99304–99306 Subsequent Nurse Facility Care
  • 5.3 Critical Care Codes
  • 5.4 Case Management Services
  • 5.5 E/M in the Global Surgical Package
  • 5.6 Evaluation and Management Modifiers Newborn and Pediatric Evaluation and Management Care

ANESTHESIA CODING

Learning Outcomes:

PC 160

  • 6.1 Types of Anesthesia
  • 6.2 Coding Anesthesia Services Anesthesia Guidelines
  • 6.3 Time Reporting
  • 6.4 Qualifying Circumstances
  • 6.5 Moderate (Conscious) Sedation Unusual Anesthesia Same Provider
  • 6.6 Physical Status Modifiers HCPCS Level II Modifiers

SURGERY CODING, PART 1

Learning Outcomes:

PC 170

  • 7.1 Types of Surgical Procedures Prophylactic, Diagnostic, and Therapeutic Procedures Surgical Approaches
  • 7.2 The Surgical Package Services Always Included Services Not Included
  • 7.3 Global Period Time Frames Services Provided By More Than One Physician
  • 7.4 Unusual Services and Treatments
  • 7.5 Surgery Guidelines Separate Procedure
  • 7.6 Integumentary System Incision and Drainage (I&D)

SURGERY CODING, PART 2

Learning Outcomes:

PC 180

  • 8.1 Musculoskeletal System
  • 8.2 Respiratory System Sinus Endoscopy Lung Transplantation
  • 8.3 Cardiovascular System Pacemakers
  • 8.4 Digestive System
  • 8.5 Urinary System
  • 8.6 Male Genital System
  • 8.7 Female Genital System Maternity Care and Delivery
  • 8.8 Nervous System
  • 8.9 Eye and Ocular Adnexa
  • 8.10 Auditory System

RADIOLOGY CODING

Learning Outcomes:

PC 190

  • 9.1 Technical vs. Professional
  • 9.2 Screening vs. Diagnostic
  • 9.3 Procedures with or without Contrast
  • 9.4 Diagnostic Radiology
  • 9.5 Radiation Oncology
  • 9.6 Nuclear Medicine Chapter Summary

PATHOLOGY AND LABORATORY CODING 271 Panels Testing Methodology and Sources

Learning Outcomes:

PC 200

  • 10.1 Clinical Chemistry
  • 10.2 Molecular Diagnostics
  • 10.3 Hematology and Coagulation Immunology Microbiology
  • 10.4 Cytopathology and Cytogenetic Studies
  • 10.5 Surgical Pathology Pathologic Testing on Bone Marrow
  • 10.6 Modifiers for Laboratory Coding

MEDICINE CODING 298

Learning Outcomes:

PC 210

  • 11.1 Immunizations
  • 11.2 Injections and Infusions Multiple Administrations
  • 11.3 Psychiatry, Psychotherapy, and Biofeedback
  • 11.4 Dialysis Gastroenterology
  • 11.5 Ophthalmology Otorhinolaryngologic Services
  • 11.6 Cardiovascular Services

CATEGORY II AND CATEGORY III CODING 330

Learning Outcomes:

PC 220

  • 12.1 Category II Codes
  • 12.2 Alphabetic Measure Index of Performance Measures
  • 12.3 Category II Modifiers
  • 12.4 Physician Quality Reporting System (PQRS)
  • 12.5 Category III Codes
  • 12.6 Category III Notations PART II HCPCS Level II

HCPCS LEVEL II CODING: INTRODUCTION AND GUIDELINES

Learning Outcomes:

PC 230

  • 13.1 HCPCS Level II Categories
  • 13.2 The Alphabetic Index
  • 13.3 The Alphanumeric Listing Overview
  • 13.4 Symbols and Notations
  • 13.5 Appendixes

HCPCS LEVEL II MODIFIERS

Learning Outcomes:

PC 240

  • 14.1 Level II Modifier Guidelines
  • 14.2 Multiple Modifiers
  • 14.3 The Modifiers
  • 14.4 Providers
  • 14.5 Claims and Documentation

CODING MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT, PHARMACEUTICAL, AND AMBULANCE AND OTHER TRANSPORTATION SERVICES

Learning Outcomes:

PC 250

  • 15.1 Coding Medical Supplies A Codes and B Codes
  • 15.2 Coding Durable Medical Equipment (DME) Durable Medical Equipment HCPCS E Code Subheadings
  • 15.3 Coding Pharmaceutical Services
  • 15.4 Generic Names and Brand Names Appendix 1—Table of Drugs Notations Quantity Specifications Measurement Equivalents J Codes
  • 15.5 Coding Ambulance and Other Transportation Services Coding Components Transportation Codes in Other Sections Ambulance Origin/Destination
  • 15.6 Transportation Waiting Time Ambulance Billing Indicators Chapter Summary PART III Inpatient Procedure Coding

INTRODUCTION TO ICD-10-PCS

Learning Outcomes:

PC 260

  • 16.1 The Objectives for ICD-10-PCS
  • 16.2 ICD-10-PCS Code Descriptions
  • 16.3 The Structure of ICD-10-PCS Codes
  • 16.4 The ICD-10-PCS ebook
  • 16.5 ICD-10-PCS General Conventions
  • 16.6 Selection of Principal Procedure
  • 16.7 General Equivalence Mappings (GEMs)

ICD-10-PCS MEDICAL AND SURGICAL SECTION

Learning Outcomes:

PC 270

  • 17.1 Character Definitions
  • 17.2 Character Position 3: Root Operation
  • 17.3 Character Position 4: Body Part: 0–9, B–Y
  • 17.4 Character Position 5: Approach
  • 17.5 Character Position 6: Device
  • 17.6 Character Position 7: Qualifier Multiple Procedures Discontinued Procedures

OBSTETRICS THROUGH CHIROPRACTIC

Learning Outcomes:

PC 280

  • 18.1 Character Definitions

IMAGING THROUGH SUBSTANCE ABUSE TREATMENT SECTIONS (B–H)

Learning Outcomes:

PC 290

  • 19.1 Character Definitions

Diagnosis Coding

INTRODUCTION TO DIAGNOSTIC CODING

Learning Outcomes:

DC 100

  • Medical Necessity Risk Factors Signs and Symptoms Procedures and Services
  • Seven Steps to Accurate Coding Coding from Physician’s Notes
  • Official ICD–CM Guidelines for Coding and Reporting
  • Rules for Ethical and Legal Coding Resources Foundational Knowledge Abbreviations—Do Not Use
  • American Health Information Management Association Code of Ethics
  • AAPC Code of Ethical Standards

INTRODUCTION TO ICD–CM The Format of the ICD–CM ebook The Coding Process

Learning Outcomes:

DC 110

  • Abstracting Physician’s Notes
  • The Alphabetic Index
  • The Tabular List
  • Z Codes
  • External Cause Codes V-Y
  • Sequelae (Late Effects) Seventh Character “S” for Sequela Sequelae (Late Effects) of External Cause Sequelae of Cerebrovascular Disease Sequelae of Complication of Pregnancy, Childbirth, and the Puerperium

GENERAL GUIDELINES AND NOTATIONS

Learning Outcomes:

DC 120

  • Three-Character Codes Categories Four-Character, Five-Character, and Six-Character Codes (Subcategories)
  • Placeholder Character
  • Seventh Character Notations Includes, Excludes, and Excludes Code First Use Additional Code Code Also Category Notes And Other Notations
  • Punctuation Combination Codes
  • Which Conditions to Code
  • Multiple and Additional Codes How Many Codes Do You Need? Code Sequencing Acute and Chronic Conditions Two or More Conditions—Only One Confirmed Diagnosis Differential Diagnoses Other Current Conditions Test Results Preoperative Evaluations Preoperative/Postop vi CONTENTS CODING INFECTIOUS DISEASES
  • Pathogens Bacteria Viruses Parasites Fungi Infection and Inflammation
  • Communicable Disease
  • Human Immunodeficiency Virus Infections Testing for Human Immunodeficiency Virus Test Negative Test Inconclusive Test Positive but Asymptomatic Test Positive with Symptoms or Manifestations HIV Status with Unrelated Conditions HIV Status in Obstetrics
  • Septicemia and Other Blood Infections Sepsis Severe Sepsis Septic Shock Sepsis and Septic Shock Relating to Pregnancy or Newborns Septic Condition Resulting from Surgery Systemic Inflammatory Response Syndrome Without Infection
  • Methicillin-Resistant Staphylococcus Aureus Methicillin-Resistant Staphylococcus Aureus Colonization Methicillin-Resistant Staphylococcus Aureus Infection Tuberculosis Bacterial Infections
  • Other Infections Viral Hepatitis Meningitis Tetanus (Lockjaw) Influenza Sexually Transmitted Diseases Varicella Rubeola Rubella Mumps Parasitic Infestations

CODING NEOPLASMS

Learning Outcomes:

DC 130

  • Testing Screenings Confirming a Diagnosis
  • Neoplasms The Neoplasm Table
  • Malignant Primary Malignant Secondary Ca in Situ Benign Uncertain Unspecified Behavior Functional Activity Overlapping Boundaries Neoplasms and Morphology Codes (M Codes)
  • Coding Sequences Excised Malignancies Prophylactic Organ Removal
  • Chemotherapy and Radiation Therapy
  • Admissions for Treatment of Complications

CODING DISEASES OF THE BLOOD AND IMMUNE MECHANISM

Learning Outcomes:

DC 140

  • The Formation of Blood
  • Antigens on Red Blood Cells
  • Blood Roles
  • Blood Tests
  • Blood Conditions Anemia Clotting Disorders
  • Disorders of the Immune Mechanism

CODING CONDITIONS OF THE ENDOCRINE AND METABOLIC SYSTEMS

Learning Outcomes:

DC 150

  • The Endocrine System Endocrine Glands Disorders of the Endocrine System
  • Diabetes Mellitus
  • Diabetic Manifestations
  • Long-Term Insulin Use Hyperglycemia Hypothyroidism (Adults) Cushing’s Syndrome
  • Functional Activity of Hormones in Neoplasms Insulin Pumps Diabetes Insipidus
  • Weight Factors Obesity Body Mass Index Underweight Other Metabolic Disorders Thyroid Disorders

CODING MENTAL AND BEHAVIORAL DISORDERS Brain Neurons

Learning Outcomes:

DC 160

  • Mental Disorders due to Known Physiological Conditions Vascular Dementia Amnestic Disorder due to Known Physiological Condition Mood Disorder due to Known Physiological Condition Personality and Behavioral Disorders due to Known Physiological Condition
  • Mental and Behavioral Disorders due to Psychoactive Substance Use Reporting Alcohol- and Drug-Related Disorders
  • Schizophrenia, Schizotypal, Delusional, and Other Nonmood Psychotic Disorders Schizophrenia Schizoid Personality Disorder (F.)
  • Mood (Affective) Disorders Bipolar Disorders Major Depressive Disorder
  • Anxiety, Dissociative, Stress-Related, Somatoform, and Other Nonpsychotic Mental Disorders Phobias Somatoform Disorders
  • Stress-Related Disorders

CODING NERVOUS SYSTEM CONDITIONS

Learning Outcomes:

DC 170

  • Types of Nerves
  • Dominant and Nondominant Sides
  • Central Nervous System The Brain The Spinal Cord
  • Peripheral Nervous System Cranial Nerves Spinal Nerves
  • Neurologic Disorders Diagnostic Testing Inflammatory Conditions of the Central Nervous System Hereditary and Degenerative Diseases of the Central Nervous System Diseases of the Peripheral Nervous System Treatments Hydrocephalus Cerebral Aneurysm Migraine Headaches Cerebrovascular Accident
  • Pain Management Reporting Pain Separately Postprocedural Pain Site-Specific Pain Codes Sequencing Pain Codes with Other Codes

CODING DISEASES OF THE EYE AND ADNEXA

Learning Outcomes:

DC 180

  • Optical System Anatomy Interior of the Eye The Muscles of the Eye The Exterior of the Eye The Lacrimal Apparatus Optical System–Related Abbreviations
  • Diseases of the Optical System Diseases of the Eyelid, Lacrimal System, and Orbit Disorders of the Conjunctiva
  • Disorders of the Sclera, Cornea, Iris, and Ciliary Body Disorders of the Lens Disorders of the Choroid and Retina
  • Glaucoma
  • Co-morbidities and Underlying Conditions Diabetic Retinopathy
  • Hypertensive Retinopathy

CODING DISEASES OF THE AUDITORY SYSTEM (EARS)

Learning Outcomes:

DC 190

  • The Anatomy of the Ear External Ear Middle Ear Inner Ear
  • Diagnosing Hearing Loss Causes of Hearing Loss Sound Levels
  • Signs and Symptoms of Hearing Loss
  • Diagnostic Testing
  • Most Common Auditory Dysfunctions
  • Treatment Options

CODING CIRCULATORY CONDITIONS

Learning Outcomes:

DC 200

  • Circulatory System Anatomy The Heart Conduction Mechanisms The Circulatory System Cardiovascular Dysfunction
  • Signs and Symptoms of Cardiovascular Disease
  • Hypotension and Hypertension Blood Pressure Hypertension versus Elevated Blood Pressure
  • Common Hypertensive Manifestations Hypertension with Heart Disease Hypertensive Heart Disease with Heart Failure Hypertensive Chronic Kidney Disease Hypertensive Heart and Chronic Kidney Disease Secondary Hypertension Hypertension and Pregnancy Hypertensive Retinopathy Hypertensive Cerebrovascular Disease Other Circulatory Conditions
  • CVA and Cerebral Infarction Heart Failure Myocardial Infarction Deep Vein Thrombosis Atherosclerotic Coronary Artery Disease (ACAD)
  • Sequelae of Cerebrovascular Disease Other Cardiovascular Conditions

CODING RESPIRATORY CONDITIONS

Learning Outcomes:

DC 210

  • Anatomy of the Respiratory System The Upper Respiratory System The Lower Respiratory System Respiratory Disorders
  • Underlying Causes of Respiratory Disorders
  • Tobacco Involvement Diagnostic Testing Pleural Disorders Pulmonary Embolism Infectious Respiratory Diseases Respiratory Syncytial Virus Infections Pulmonary Fibrosis
  • Pneumonia and Influenza Pneumonia Influenza Pneumonia as a Manifestation of HIV
  • Chronic Obstructive Pulmonary Disease Exacerbation and Status Asthmaticus
  • Respiratory Conditions Requiring External Cause Codes External Cause Codes Respiratory Failure Ventilator-Associated Pneumonia

CODING DISEASES OF THE DIGESTIVE SYSTEM

Learning Outcomes:

DC 220

  • The Digestive Diagnostic Testing Pathology and Laboratory
  • Endoscopy Digestive Conditions
  • Ulcers
  • Hernias
  • Hepatitis Cirrhosis
  • Cholecystitis

CODING DISEASES OF THE INTEGUMENTARY SYSTEM

Learning Outcomes:

DC 230

  • The Integumentary System Anatomy The Skin Hair Nails Glands Sensory Nerves Conditions of the Skin
  • Pressure Ulcers Healing Pressure Ulcers Presence of Gangrene
  • Lesions Malignant Lesions
  • Dermatitis
  • Psoriasis
  • Disorders of Skin Appendages Nail Disorders Disorders of the Hair Glandular Concerns

CODING MUSCULAR CONDITIONS

Learning Outcomes:

DC 240

  • Types of Muscle Actions
  • Joint-Related Components Muscles throughout the Body
  • Traumatic Injury to the Muscles
  • Infection and Inflammation of the Muscles
  • Diseases of the Muscles
  • Reporting External Causes Cause of the Injury Code Place of the Occurrence Code Activity Code Patient’s Status

CODING SKELETAL CONDITIONS Categories of Bones

Learning Outcomes:

DC 250

  • The Axial Skeleton The Skull The Bones of the Ear The Hyoid Bone The Spine The Rib Cage (Bony Thorax)
  • The Appendicular Skeleton The Pectoral Girdle The Upper Limb The Pelvic Girdle The Lower Limb The Ankle and Foot
  • Fractured Bones Types of Fractures
  • Pathophysiological Fractures and Conditions
  • Sequelae (Late Effects) of Fractures
  • Seventh Character

CODING DISEASES OF THE URINARY SYSTEM

Learning Outcomes:

DC 260

  • The Urinary System The Kidneys The Ureters The Urinary Bladder The Urethra
  • Renal and Urologic Malfunctions Diagnostic Tools
  • Chronic Kidney Disease
  • CKD with Other Conditions Acute Renal Failure
  • Urinary Tract Infection Renal Calculi
  • Conditions Affecting the Prostate Prostatitis Benign Prostatic Hyperplasia Malignant Neoplasm of the Bladder

CODING FOR OBSTETRICS AND GYNECOLOGY

Learning Outcomes:

DC 270

  • The Female Genital System The Breast Internal Female Genitalia External Female Genitalia
  • Reproduction Fertilization and Gestation Weeks of Gestation
  • Routine Obstetrics Care Prenatal Visits
  • Pregnancies with Complications Preexisting Conditions Affecting Pregnancy Gestational Conditions Multiple Gestations Fetal Abnormalities Seventh Character
  • Labor and Delivery Normal Delivery Special Circumstances Related to Delivery Outcome of Delivery Postpartum and Peripartum Conditions Sequelae (Late Effects) of Obstetric Complications Abortive Outcomes Routine Encounters Procreative Management
  • Other Gynecologic Conditions Endometriosis Uterine Fibroids Pelvic Pain Sexually Transmitted Diseases

CODING CONGENITAL AND PEDIATRIC CONDITIONS

Learning Outcomes:

DC 280

  • Coding the Birth
  • Routine Well-Baby Checkups
  • Clinically Significant Conditions
  • Maternal Conditions Affecting the Infant Perinatal Sepsis
  • Genetics
  • Genetic Conditions versus Congenital Malformation Genetic Disorders Chromosomal Abnormalities Autosomal Recessive Inherited Diseases Multifactorial Abnormalities X-Linked Inherited Diseases Congenital Malformations Fetal (Prenatal) Surgery

CODING INJURIES, POISONINGS, AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES

Learning Outcomes:

DC 290

  • Traumatic Wounds Lacerations (Superficial Wounds) Contusions and Hematomas Puncture Wounds Avulsions Animal, Insect, or Human Bites Foreign Bodies
  • Burns Site Severity Specific Site Multiple Sites Fall into the Same Code Category Extent Infection in the Burn Site Solar and Radiation Burns Sequelae (Late Effects) of Burns and Corrosions
  • Adverse Effects, Poisoning, Underdosing, and Toxic Effects Adverse Reaction: Sixth Character The Five Rights of Drug Administration Administration Routes Poisoning The Table of Drugs and Chemicals Drug and Chemical Names Patient Noncompliance Substance Interactions
  • Abuse, Neglect, and Maltreatment
  • Complications of Care (T–T)
  • External Cause Codes

FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITH HEALTH SERVICES

Learning Outcomes:

DC 300

  • Preventive Care
  • Early Detection
  • Genetic Susceptibility
  • Observation
  • Continuing Care and Aftercare
  • Obstetrics (Prenatal) and Neonatal Exams Organ Donation
  • Resistance to Antimicrobial Drugs
  • Z Codes As First-Listed/Principal Diagnosis

HOSPITAL (INPATIENT) DIAGNOSIS CODING

Learning Outcomes:

DC 310

  • Concurrent and Discharge Coding
  • Official Coding Guidelines Uncertain Diagnosis Patient Receiving Diagnostic Services Only
  • Present on Admission Indicators General Reporting Guidelines POA Indicators
  • Diagnosis-Related Groups Principal Diagnosis
  • Complications and Co-morbidities Major Complications and Co-morbidities
  • Uniform Hospital Discharge Data

Medical Records Practicum, Apprenticeship, and Capstone

Learning Outcomes:

BC 400

This course is part of your three-course series that instructs students how to become experienced in medical coding. This course was designed for medical coding students to learn step-by-step instructions and conversational terminology to increase understanding of the medical coding process, offering a wide range of opportunities for students to apply billing and coding on a case-by-case basis. Students will practice abstracting codes from real-world health facility documents and records, effectively translating facts into the best and most appropriate codes.

Learning Outcomes:

  • HOW TO ABSTRACT NOTES
  • ALLERGY AND IMMUNOLOGY CASES AND PATIENT RECORDS
  • CARDIOLOGY AND CARDIOVASCULAR CASES AND PATIENT RECORDS
  • DENTISTRY CASES AND PATIENT RECORDS
  • DERMATOLOGY AND BURNS CASES AND PATIENT RECORDS
  • EMERGENCY SERVICES CASES AND PATIENT RECORDS
  • ENDOCRINOLOGY CASES AND PATIENT RECORDS
  • FAMILY PRACTICE CASES AND PATIENT RECORDS
  • GASTROENTEROLOGY CASES AND PATIENT RECORDS
  • GERONTOLOGY CASES AND PATIENT RECORDS
  • NEONATAL AND PEDIATRICS CASES AND PATIENT RECORDS
  • NEUROLOGY CASES AND PATIENT RECORDS
  • OBSTETRICS AND GYNECOLOGY CASES AND PATIENT RECORDS
  • ONCOLOGY CASES AND PATIENT RECORDS
  • OPHTHALMOLOGY CASES AND PATIENT RECORDS
  • ORTHOPEDICS CASES AND PATIENT RECORDS
  • OTOLARYNGOLOGY CASES AND PATIENT RECORDS
  • PATHOLOGY AND LABORATORY CASES AND PATIENT RECORDS
  • PLASTIC AND RECONSTRUCTIVE SURGERY CASES AND PATIENT RECORDS
  • PODIATRY CASES AND PATIENT RECORDS
  • PSYCHIATRIC CASES AND PATIENT RECORDS
  • PULMONARY AND RESPIRATORY CASES AND PATIENT RECORDS
  • RADIOLOGY AND NUCLEAR MEDICINE CASES AND PATIENT RECORDS
  • UROLOGY, NEPHROLOGY, AND MEN’S HEALTH CASES AND PATIENT RECORDS
  • ALTERNATIVE MEDICINE: ACUPUNCTURE, CHIROPRACTICS, AND PHYSICAL THERAPY CASES AND PATIENT RECORDS
  • INPATIENT (ACUTE CARE) RECORDS

After successful completion of this study course students participate in the Apprenticeship and Capstone to perform skills required of a practicing Medical Records Information Technician​.

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