Apr 13, 2024  
2023-2024 College Catalog 
    
2023-2024 College Catalog [ARCHIVED CATALOG]

MDA 125 - Orientation to ICD-10-CM and CPT Coding

3 Credits, 3 Contact Hours
3 lecture periods 0 lab periods

Orientation to the International Classification of Diseases -10th Edition (ICD-10) coding classification system. Includes terminology, principles and components of the ICD-10 system, codes for diseases and conditions, coding from health records, and coding for the highest specificity.

Recommendation: Completion of MDA 121  and MDA 124  before enrolling in this course. Also a minimum of 25 words per minute word processing skills. If any recommended course is taken, see a financial aid or Veteran’s Affairs advisor to determine funding eligibility as appropriate.
Information: Students must be admitted to the Medical Assistant program or obtain consent of instructor before enrolling in this course.
Button linking to AZ Transfer course equivalency guide    button image Prior Learning and link to PLA webpage



Course Learning Outcomes

1.  Assign accurate ICD-10-CM codes for diagnosis of diseases and conditions following governmentally approved guidelines, modifiers and conventions.

2.  Identify and select CPT Category I and HCPCS Level II codes for procedures and services performed and determined medically necessary based on evidence-based clinical standards of care.

3.  Abide by established laws and display a high level of personal and professional standards.


Outline:
  1. Concepts of Effective Communication
    1. Communication skills with medical providers
    2. Subjective and objective information
    3. Accurate and concise information
    4. Sensitivity to patient rights
    5. Community resources
  2. Administrative Functions
    1. Information in patient’s medical record
    2. Organization of the patient’s medical record
      1. Problem-oriented medical record (POMR)
      2. Source-oriented medical record (SOMR)
    3. Electronic Documentation
      1. Electronic Medical Record (EMR)
      2. Electronic Health Record
    4. Practice Management System
  3. International Classification of Disease (ICD-10-CM) Diagnostic Coding
    1. Coding Guidelines
      1. Conventions

 

  1. General Guidelines
  2. Chapter Specific Guidelines
  3. Diagnostic Statement
    1. Main Terms
    2. Modifying Terms
  4. Alphabetic Index
    1. Main terms
    2. Nonessential modifiers
    3. Essential modifiers
    4. Sub terms
    5. Supplementary tables
  5. Tabular List
    1. Conventions in Tabular List
      1. Placeholders
      2. Seven Character Codes
      3. Punctuation
      4. Instructional Notations
      5. Cross Reference Notes
      6. Relational Terms
    2. NEC and NOS Codes
  6. Final ICD-10-CM code selection
  7. Medical Necessity
  1. Current Procedural Terminology (CPT) Coding
    1. CPT Coding
      1. Modifiers
      2. Conventions
    2. Alphabetic Index
      1. Procedure or Service
      2. Organ or Site
      3. Condition, Illness or Injury
      4. Synonym, Eponym or Abbreviation
    3. Tabular List
      1. Evaluation and Management
      2. Anesthesia
      3. Surgery
      4. Radiology
      5. Pathology and Laboratory
      6. Medicine
    4. Final CPT Code Selection
    5. Healthcare Common Procedure Coding System (HCPCS Level II)
  1. Legal Implications
    1. Upcoding
    2. Downcoding
    3. HIPAA rules and privacy
    4. Release of information
    5. Integrity of the medical record
  2. Ethical Considerations
    1. Professional Performance
      1. Ethics
      2. Morals
    2. Personal Values


Effective Term:
Fall 2023