2024-2025 College Catalog
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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.
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:
- Concepts of Effective Communication
- Communication skills with medical providers
- Subjective and objective information
- Accurate and concise information
- Sensitivity to patient rights
- Community resources
- Administrative Functions
- Information in patient’s medical record
- Organization of the patient’s medical record
- Problem-oriented medical record (POMR)
- Source-oriented medical record (SOMR)
- Electronic Documentation
- Electronic Medical Record (EMR)
- Electronic Health Record
- Practice Management System
- International Classification of Disease (ICD-10-CM) Diagnostic Coding
- Coding Guidelines
- Conventions
- General Guidelines
- Chapter Specific Guidelines
- Diagnostic Statement
- Main Terms
- Modifying Terms
- Alphabetic Index
- Main terms
- Nonessential modifiers
- Essential modifiers
- Sub terms
- Supplementary tables
- Tabular List
- Conventions in Tabular List
- Placeholders
- Seven Character Codes
- Punctuation
- Instructional Notations
- Cross Reference Notes
- Relational Terms
- NEC and NOS Codes
- Final ICD-10-CM code selection
- Medical Necessity
- Current Procedural Terminology (CPT) Coding
- CPT Coding
- Modifiers
- Conventions
- Alphabetic Index
- Procedure or Service
- Organ or Site
- Condition, Illness or Injury
- Synonym, Eponym or Abbreviation
- Tabular List
- Evaluation and Management
- Anesthesia
- Surgery
- Radiology
- Pathology and Laboratory
- Medicine
- Final CPT Code Selection
- Healthcare Common Procedure Coding System (HCPCS Level II)
- Legal Implications
- Upcoding
- Downcoding
- HIPAA rules and privacy
- Release of information
- Integrity of the medical record
- Ethical Considerations
- Professional Performance
- Ethics
- Morals
- Personal Values
Effective Term: Fall 2023
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