MDA 135 - Clinical Coding, Billing, and Insurance

4 Credits, 6 Contact Hours
3 lecture periods 3 lab periods
Introduction to the processes and procedures related to the International Classification of Diseases -10th Edition, Clinical Modification (ICD-10 CM) and the Current Procedural Terminology (CPT) systems. Includes terminology, principles, and components of each system, codes for diseases and conditions using the Electronic Health Record (EHR). Also includes introduction to health insurance plans in an ambulatory care environment, principles of bookkeeping, billing, accounting, and banking. 

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 Veterans Affairs advisor to determine funding eligibility as appropriate.
 

1. Describe Explanation of Benefits (EOB)
2. Differentiate among payer types and patient responsibilities
3. Explain third party payers such as Medicare, Medicaid, and Private Insurers
4. Explain the differences of HMOs, PPOs, EPOs IOSs, IPAs, and consumer directed plans
5. Apply ICD-10-CM and CPT codes according to current guidelines 
6. Apply policies and procedures for the use of data required in health care reimbursement.

1. Review insurance claim forms for accuracy (terminology, insurance plan, current codes, HIPAA regulations)
2. Identify and enter diagnosis/procedure codes and charges accurately
3. Post charges and reconcile daily receivables

1. Overview of Coding
   1. Classification systems, nomenclatures, and terminology
   2. Health Information Portability and Accountability Act
   3. International Classification of Diseases,Clinical Modification (ICD-10-CM)
      1. Tabular list of diseases and injuries
      2. General ICD-10-CM diagnosis coding guidelines
      3. ICD Code Book Navigation
   4. Current Procedural Terminology (CPT) Coding
      1. Organization of CPT
      2. Index, appendices, and symbols
      3. Sections, Subsections, Categories, and Subcategories
         1. Surgery
         2. Radiology
         3. Pathology and Laboratory
         4. Medicine
      4. CPT modifiers
2. Principles of Health Insurance and Medical Billing
   1. Health Insurance History
   2. Health Insurance Terminology
      1. Common Insurance Terms
      2. Common Diagnostic and Legal Terms
      3. Abbreviations
      4. Symbols
   3. Federal, States, and Private Insurance Plans
   4. Claims Completion
   5. Insurance Problem Solving
   6. Client Eligibility and Reimbursement Procedures
      1. Econutner forms
      2. Collection Procedures
      3. Billing and Receiving
      4. Co-payments
      5. Timing of Payments