ALH5241 REIMBURSEMENT METHODOLOGIES (PHYSICIAN)
3 Credit Hours
This course is open to students on the college level in either the freshman or sophomore year.
ALH5241 - Reimbursement Methodologies (Physician) (3 hrs)
This course is designed to incorporate all concepts presented in CPT and ICD Coding into real life coding situations and to explain the process of healthcare reimbursement in an understandable format. This is the second set of courses in medical coding.
ALH 5240 Current Procedural Terminology (CPT) Coding and ALH5242 Internal Classification of Disease (ICD)
ALH5249 Medical Coding Practicum
This course is designed to help the student increase their knowledge concerning medical coding and billing as well as healthcare reimbursement and is the third in a series of medical coding classes that should be taken concurrently to fully understand the concepts of coding in the medical profession.
Upon completion of the course, the student will be able to understand the ICD-CM Manual and the various sections that describe the medical, surgical and diagnostic services. This course will also describe and explain Healthcare Reimbursement including Medicare, Medicaid and Workers Compensation Programs.
Reimbursement Methodologies will also include a brief review of CPT, ICD and HCPCS coding, followed by legal and regulatory issues connected with the healthcare industry. Previous concepts covered will be revisited and evaluated.
Unit Outcomes for Criterion Based Evaluation:
The following outline defines the minimum core content not including the final examination period. Instructors may add other material as time allows.
UNIT 1: KBOR Aligned Competencies
Outcomes: The student will gain an understanding of the basics of reimbursement methodologies.
- Analyze significant health record data for accurate reimbursement
- Apply coding and payment methodologies utilized for reimbursement
- Analyze third-party reimbursement for healthcare services
- Explain the significance of the health record in the revenue cycle
- Query physicians to ensure accurate reimbursement
- Identify the importance of coding quality in compliance
- Distinguish among the various auditing methods
- Examine legal and ethical dilemmas in the reimbursement process
- Utilize resources to stay current with changing reimbursement practices
- Analyze significant health record data for accurate physician-based setting reimbursement
- Apply coding and payment methodologies utilized for physician-based setting reimbursement
- Analyze third-party reimbursement for physician-based setting healthcare services
- Query physician documentation to ensure accurate reimbursement
- Distinguish among the various auditing methods specific to the physician-based setting
- Examine legal and ethical dilemmas in a physician-based setting reimbursement process
- Recognize payer specific guidelines that impact physician-based setting reimbursement
- Utilize resources to stay current with changing physician-based setting reimbursement practices
UNIT 2: Overview of the ICD-CM
Outcomes: The student will gain an understanding of the basics of the ICD-CM manual.
- Explain the use of the CPT & ICD-CM Manuals.
- Demonstrate the ability to properly code using the CPT & ICD-CM guidelines.
- Apply knowledge of ICD-CM coding conventions when assigning cases.
- Apply knowledge of ICD-CM Tabular Index, Alphabetic Index and
- Procedures Index.
- Demonstrate an understanding of ICD-CM
UNIT 3: Using the THE ICD-CM
Outcomes: The student will gain an understanding of using the ICD-CM to code specific medical disorders.
- Discuss the development of the Official Guidelines for Coding and Reporting.
- Apply the Official Guidelines for Coding and Reporting.
- Define the steps to diagnosis coding.
- Review infectious and parasite diseases coding.
- Analyze the neoplasms coding.
- Examine the endocrine, nutritional, metabolic diseases, and immunity disorders
- Review the blood conditions, mental disorders, nervous system, and sense
- organs coding.
- Review the circulatory system coding.
- Analyze the respiratory system coding.
- Discuss the digestive system coding.
- Review the genitourinary system coding.
- Discuss the pregnancy, childbirth, and puerperium coding.
- Review the skin and subcutaneous tissue coding.
- Discuss the congenital anomalies and certain conditions originating in the
- perinatal period coding.
- Define the rules of symptoms, signs, and ill-defined conditions coding.
- Review the outpatient coding guidelines.
- Explain the format of new ICDCM.
UNIT 4: Third-Party Reimbursement Issues
Outcomes: The student will gain an understanding of legalities and regulations regarding third-party reimbursement.
- Demonstrate an understanding of basic Healthcare Reimbursement.
- Distinguish between Medicare Part A, Medicare Part B, and Medicaid.
- Demonstrate an understanding of the RBRVS System
- Demonstrate an understanding of the DRG System
- Discuss both Federal & State Workers’ Compensation Programs
- Explain the purpose of PROs.
- Understand and identify the major components of Managed Healthcare.
- Locate information in the Federal Register.
- State the structure of the APC system.
- Discuss the framework of Medicare fraud and abuse.
Varies, see course syllabus.
Contact Bookstore for current textbook.
Computers and Printers
Students should adhere to the attendance policy outlined by the instructor in the course syllabus.
The grading policy will be outlined by the instructor in the course syllabus.
Maximum class size:
Based on classroom occupancy
Course Time Frame:
The U.S. Department of Education, Higher Learning Commission and the Kansas Board of Regents define credit hour and have specific regulations that the college must follow when developing, teaching and assessing the educational aspects of the college. A credit hour is an amount of work represented in intended learning outcomes and verified by evidence of student achievement that is an institutionally-established equivalency that reasonably approximates not less than one hour of classroom or direct faculty instruction and a minimum of two hours of out-of-class student work for approximately fifteen weeks for one semester hour of credit or an equivalent amount of work over a different amount of time. The number of semester hours of credit allowed for each distance education or blended hybrid courses shall be assigned by the college based on the amount of time needed to achieve the same course outcomes in a purely face-to-face format.
Refer to the following policies:
402.00 Academic Code of Conduct
263.00 Student Appeal of Course Grades
403.00 Student Code of Conduct
Disability Services Program:
Cowley College, in recognition of state and federal laws, will accommodate a student with a documented disability. If a student has a disability which may impact work in this class which requires accommodations, contact the Disability Services Coordinator.