HITT 2240 - Advanced Medical Billing and Reimbursement

HITT 2240:

Description

Skill development in coding to prepare reimbursement forms in various health care settings for submission to payors.

Semester Offered

Fall and Spring semesters

Credits 2 Lecture Hours 2 Lab Hours 1

Extended Hours

Contact Hours

State Approval Code

51.0713

Alternate Operations During Campus Closure

In the event of an emergency or announced campus closure due to a natural disaster or pandemic, it may be necessary for Panola College to move to altered operations. During this time, Panola College may opt to continue delivery of instruction through methods that include, but are not limited to: online learning management system (CANVAS), online conferencing, email messaging, and/or an alternate schedule. It is the responsibility of the student to monitor Panola College's website (www.panola.edu) for instructions about continuing courses remotely, CANVAS for each class for course-specific communication, and Panola College email for important general information.

Class Attendance

Regular and punctual attendance of classes and laboratories is required of all students. When a student has been ill or absent from class for approved extracurricular activities, he or she should be allowed, as far as possible, to make up for the missed work. If a student has not actively participated by the census date, they will be dropped by the instructor for non-attendance. This policy applies to courses that are in-person, online, hybrid, and hyflex.

Attendance in online courses is determined by submission of an assignment or participation in an activity. According to federal guidelines, simply logging into a distance learning course without participating in an academic assignment does not constitute attendance. Distance learning is defined as when a majority (more than 50%) of instruction occurs when the instructor and students are in separate physical locations. Students must engage in an academic activity prior to the course census date.

When an instructor feels that a student has been absent to such a degree as to invalidate the learning experience, the instructor may recommend to the Vice President of Instruction that the student be withdrawn from the course. Instructors may seek to withdraw students for non-attendance after they have accumulated the following number of absences:

Fall or spring semesters:

3 or more class meeting times per week - 5 absences

2 class meeting times per week - 3 absences

1 class meeting per week - 2 absences

The student is responsible for seeing that he or she has been officially withdrawn from a class. A student who stops attendance in a class without officially withdrawing from that class will be given a failing grade; consequently, the student must follow official withdrawal procedures in the Admissions/Records Office.

Please note: Health Science and Cosmetology courses may require more stringent attendance policies based on their accreditation agencies. Please see the addendum and/or program handbook for further information concerning attendance.

Pregnant/Parenting Policy

Panola College welcomes pregnant and parenting students as a part of the student body. This institution is committed to providing support and adaptations for a successful educational experience for pregnant and parenting students. Students experiencing a need for accommodations related to pregnancy or parenting will find a Pregnancy and Parenting Accommodations Request form in the Student Handbook or may request the form from the course instructor.

Artificial Intelligence (AI) Course Policy

Use of generated AI Permitted under some classroom circumstances with permission.

There are situations throughout the course where you may be asked to use artificial intelligence (AI) tools to explore how they can be used. Outside of those circumstances, you should not use AI tools to generate content that will end up in any student work (assignments, activities, discussion responses, etc.). In such cases for Option #2, no more than 25% of the student work should be generated by AI. Use of any AI-generated content in this course without the instructor’s consent qualifies as academic dishonesty and violates Panola College’s standards of academic integrity.

Instructional Goals and Purposes

The purpose of this course is to review and expand information about major insurance programs and federal healthcare legislation; to provide a reinforcement of knowledge learned in other courses of national diagnosis and procedure coding systems; and to simplify the process of completing health insurance claim forms.

Learning Outcomes

At the conclusion of this course the student will be able to:

Code of health records using various classification systems.
Execute reimbursement forms.
Apply revenue cycle management procedures.
Facilitate the development of an insurance claim.
Interpret provider documentation to code for medical necessity.

Specific Course Objectives (includes SCANS)

After studying all materials and resources presented in the course, the student will be able to: complete all behavioral/learning objectives listed below with a minimum competency of 70% on assignments and exams.

Understand how hospitals evolved and to provide an overview of a hospital’s organizational structure and functions.
1. Define terms, phrases, abbreviations, and acronyms.
2. Provide an overview of significant factors that influenced the evolution of hospitals.
3. Outline key factors that led to the establishment of hospitals in the United States and contributed to the development of our modern-day health care delivery systems.
4. Discuss how hospitals organization structures are designed to contribute to accomplishing the hospital’s goals and mission.
5. List and describe four categories of functions in a hospital.
6. Describe functions performed by various departments.
7. Identify and discuss three services where patient care services are rendered in a hospital.
  SCANS Basic Skills: Ai, Aii, Aiv, Av, Bi, Bii, Bv, Ci, Cii, Civ, Cv
  SCANS Workplace Competencies: Ai, Aiv, Bi, Bv, Bvi, Ci, Cii, Ciii, Civ, Di, Ei, Eii, Eiii
Provide an overview of the hospital regulatory environment.
1. Define terms, phrases, abbreviations, and acronyms.
2. Describe factors that led to the government’s expanded role in regulating health care.
3. Demonstrate an understanding of federal and state legislation implemented to address health care issues and the impact of the legislation on the hospital’s regulatory environment.
4. Discuss how the creation of Medicare and Medicaid expanded the government’s role in health care regulation.
5. Provide a brief overview of federal and state regulatory agencies involved in health care regulation.
6. State the purpose of accreditation and explain why it is important.
7. Discuss various credentials required for hospital billing and coding personnel.
  SCANS Basic Skills: Ai, Aii, Aiii, Aiv, Bii, Biii, Biv, Bv, Ci, Cii, Civ, Cv
  SCANS Workplace Competencies: Ai, Bvi, Ci, Cii, Ciii, Civ, Di, Dii, Ei, Eii, Eiii
Provide a basic understanding of the patient care process and how data flow within a hospital from the time a patient is admitted to when charges are submitted for patient care services.
1. Define terms, phrases, abbreviations, and acronyms.
2. Discuss the variations in patient accounts and data flow for outpatient, ambulatory surgery, and inpatient services.
3. Outline the patient care process and provide an explanation of each phase.
4. Identify the tasks performed during the admission process and discuss forms used during the process.
5. Provide an explanation of the insurance verification process.
6. Discuss the purpose of medical record documentation and various forms and documents used in the medical record.
7. Provide an overview of patient care services provided by a hospital and explain how charges are captured for the services.
8. State the role of Health Information Management (HIM) in billing patient care services.
9. Discuss phases of the hospital billing process and how it relates to accounts receivable (A/R) management.
  SCANS Basic Skills: Ai, Aii, Aiv, Bii, Biii, Biv, Bv, Ci, Cii, Civ, Cv
  SCANS Workplace Competencies: Ai, Bvi, Ci, Cii, Ciii, Civ, Di, Dii, Ei, Eii, Eiii
Provide a basic understanding of the hospital billing process.
1. Define terms, phrases, abbreviations, and acronyms.
2. Demonstrate an understanding of the billing process and its purpose.
3. Discuss the key provisions of participating provider agreements (PAR).
4. Identify variations in claim requirements by payer type.
5. Explain the difference between traditional, fixed, and Prospective Payment Systems (PPS) reimbursement methods.
6. Discuss the content and purpose of the Charge Description Master (CDM).
7. Differentiate between coding systems required for outpatient services versus inpatient services.
8. Discuss the purpose of the detailed itemized statement and how it relates to the claim format.
9. Explain the difference between a clean and dirty claim, ad discuss the importance of submitting a clean claim.
10. Explain the significance of accounts receivable (AR) management.
11. Demonstrate an understanding of phases of the hospital revenue cycle.
  SCANS Basic Skills: Ai, Aii, Aiii, Aiv, Av, Bi, Bii, Biii, Biv, Bv, Ci, Cii, Ciii, Civ, Cv
  SCANS Workplace Competencies: Ai, Aii, Aiii, Aiv, Bi, Biv, Bv, Bvi, Ci, Cii, Ciii, Civ, Di, Dii, Ei, Eii, Eiii
Provide an overview of the evolution of diagnosis coding systems to ICD-10-CM.
1. Define terms, phrases, abbreviations, and acronyms.
2. Provide a brief overview of the evolution of diagnosis coding to ICD-10-CM.
3. Discuss the impact ICD-10 on documentation, coding, medical necessity, claim forms, and reimbursement.
4. Identify three key areas of ICD-10-CM data usage and discuss organizations that use ICD-10-CM data.
5. Demonstrate an understanding of various aspects of the ICD-10-CM transition, including certification, mapping and crosswalks, and the ICD Coordination and Maintenance Committee.
6. State key differences between ICD-10-CM and ICD-9-CM.
7. Provide coding conventions and apply coding principals related to conventions and coding.
8. Demonstrate an understanding of the steps to coding using the ICD-10-CM diagnosis coding system.
  SCANS Basic Skills: Ai, Aii, Aiv, Bii, Biii, Biv, Bv, Ci, Cii, Civ, Cv
  SCANS Workplace Competencies: Ai, Bvi, Ci, Cii, Ciii, Civ, Di, Dii, Ei, Eii, Eiii
Provide an overview of coding procedures, services and items provided during a hospital visit using HCPCS and ICD-10-PCS.
1. Define terms, phrases, abbreviations, and acronyms.
2. Demonstrate an understanding of the history and purpose of procedure coding systems.
3. Discuss how procedure coding data are used for research, education, and administrative purposes.
4. Provide an explanation of the relationship between procedure coding and documentation have medical necessity, claim forms, and reimbursement.
5. Discuss the relationship between procedure coding and diagnosis coding.
6. Identify variations in the use of coding systems for outpatient, non-patient, and inpatient services.
7. Outline the standard code set requirements for reporting procedures under HIPAA.
8. List the two levels of HCPCS and discuss the content of each system.
9. Explain the reasons why ICD-10-PCS was implemented and discuss the transition to ICD-10.
10. Outline the content of the ICD-10-PCS coding systems.
11. Demonstrate an understanding of the steps to coding using the HCPCS and ICD-10-PCS procedure coding systems and basic coding principles.
  SCANS Basic Skills: Ai, Aii, Bii, Biii, Biv, Bv, Ci, Cii, Civ, Cv
  SCANS Workplace Competencies: Ai, Aiii, Ci, Cii, Ciii, Civ, Di, Dii, Ei, Eii, Eiii
Provide basic understanding of HCPCS and ICD-10 guidelines for diagnosis and procedure coding in the hospital setting.
1. Define terms, phrases, abbreviations, and acronyms.
2. Explain the relationship between billing and coding.
3. Discuss variations in coding systems used for outpatient and inpatient services.
4. Identify standard code sets required under HIPAA regulations.
5. Demonstrate an understanding of HCPCS and ICD-10 coding principles and guidelines.
6. Provide an outline of the basic steps to coding from the medical record.
7. Demonstrate the ability to apply coding guidelines for outpatient and inpatient cases.
  SCANS Basic Skills: Ai, Aii, Bii, Biii, Biv, Bv, Ci, Cii, Civ, Cv
  SCANS Workplace Competencies: Ai, Aiii, Ci, Cii, Ciii, Civ, Di, Dii, Ei, Eii, Eiii
Provide a basic understanding of claim forms used by hospital facilities to submit charges to payers for reimbursement.
1. Define terms, phrases, abbreviations, and acronyms.
2. Explain the purpose of claim forms.
3. Describe manual and electronic claim submission and discuss advantages and disadvantages of each method.
4. Explain the difference between the CMS-1500 and CMS-1450 (UB-04) and outline when they are used.
5. Discuss variations in claim form usage and coding systems used for outpatient and inpatient claims.
6. Demonstrated and understanding of data requirements and completion instructions for the CMS-1450 (UB-04).
  SCANS Basic Skills: Ai, Aii, Bii, Biii, Biv, Bv, Ci, Cii, Civ, Cv
  SCANS Workplace Competencies: Ai, Aiii, Ci, Cii, Ciii, Civ, Di, Dii, Ei, Eii, Eiii
Provide an overview of payers that provide coverage for health care services performed in a hospital.
1. Define terms, phrases, abbreviations, and acronyms.
2. Identify and describe types of health insurance plans.
3. Discuss the differences between traditional fee-for-service and managed care plans.
4. Explain why health insurance plans and government programs implemented managed care plans.
5. Distinguish between private and government payers.
6. Describe the role of the Centers for Medicare and Medicaid Services (CMS) in government plans.
7. Discuss eligibility requirements for each government program and provide an overview of coverage for each government program.
8. Outline coordination of benefits (COB) guidelines for Medicare, Medicaid, and TRICARE.
9. Demonstrate an understanding of basic plan terms and specifications.
  SCANS Basic Skills: Ai, Aii, Aiii, Bii, Biii, Biv, Bv, Ci, Cii, Civ, Cv
  SCANS Workplace Competencies: Ai, Aii, Aiii, Aiv, Ci, Cii, Ciii, Civ, Di Dii, Ei, Eii, Eiii
Provide an overview of Prospective Payment Systems (PPS).
1. Define terms, phrases, abbreviations, and acronyms.
2. Demonstrate an understanding of the evolution of health care reimbursement from cost-based systems to Prospective Payment Systems (PPS).
3. Describe the relationship between government programs and Prospective Payment Systems (PPS) and discuss payment systems implemented under PPS.
4. Demonstrate an understanding of Inpatient Prospective Payment System (IPPS) development have payment calculations, structure, and assignment.
5. Demonstrate an understanding of Outpatient Prospective Payment System (OPPS) development, payment calculations, structure, and assignment.
  SCANS Basic Skills: Ai, Aii, Bii, Biii, Biv, Bv, Ci, Cii, Civ, Cv
  SCANS Workplace Competencies: Ai, Aiii, Ci, Cii, Ciii, Civ, Di, Dii, Ei, Eii, Eiii
Provide an overview of patient account transactions and accounts receivable management.
1. Define terms, phrases, abbreviations, and acronyms.
2. Demonstrate an understanding of the life cycle of a claim and the hospital billing process.
3. Provide an overview of key information found on a remittance advice (RA).
4. Discuss elements related to patient transactions.
5. Demonstrate an understanding of AR management reports and procedures.
6. List common reasons for claim denials and delays.
7. State the relationship between credit and collection laws and collection activities.
8. Provide an overview of the appeals process.
  SCANS Basic Skills: Ai, Aii, Aiii, Bii, Biii, Biv, Bv, Ci, Cii, Civ, Cv
  SCANS Workplace Competencies: Ai, Aii, Aiii, Ci, Cii, Ciii, Civ, Di, Dii, Ei, Eii, Eiii

Course Content

A general description of lecture/discussion topics included in this course are listed in the Learning Outcomes/Specific Course Objectives sections of this syllabus.

Students in all sections of this course will be required to do the following:

Demonstrate knowledge of course material by completing midterm examination and final examination under proctor supervision at either Panola College or an official Panola College testing center.
Read all class lecture material, which has been provided in an online format.
Use the current learning management system (LMS) to access assignments and course materials.
Use the current LMS email to communicate with the instructor.
Interact with other students through online discussion groups.
Complete all online assignments.

Course	Week	Assignment Title	AHIMA Entry-Level Competencies	Taxonomy Level
HITT 2240	5	Resource-Based Relative Value Scale	IV.2 Describe components of revenue-cycle management and clinical documentation improvement	5
HITT 2240	14	A/R days	IV. 2 (RM ONLY) Evaluate revenue cycle processes	5
HITT 2240	14	Chargemaster Issue	IV. 2 (RM ONLY) Evaluate revenue cycle processes	5

**IMPORTANT: These assignments listed about are HIT Entry Level Competencies- this means you MUST score a minimum of 70%. If you do not score a minimum of 70% on your first attempt, you will have to repeat the assignment and/or do an equivalent remedial assignment until you score 70%. THIS IS A GRADUATION REQUIREMENT.

Methods of Instruction/Course Format/Delivery

Students in the Internet class will have access to this course via the current LMS.
All assignments will be submitted through the current LMS. After the assignment has been graded, the student will be able to view his or her grades by clicking the Grades link in the left banner.
Students should use the Email within the LMS to communicate with the instructor. This email gives you access to the instructor and other classmates without having to remember or type email addresses- you must select a name from the list. If you are not able to contact me using this email, you may use my Panola College email address, contact me by telephone, or stop by my office. I attempt to respond to all email within 24 hours. Please always include a subject line and your name in your email.

Assignments

Discussion questions
Chapter quizzes (chapters 1,2,4,5,7-13)
Complete health insurance claim forms

Assessments

Major Exams
Final Exam (compressive)

Course Grade

The grading scale for this course is as follows:

Major Exams 35%
Textbook & Workbook Exercises 35%
Discussion Board Participation And Attendance 10%
Final Exam 20%

Letter Grades for the course will be assigned as follows:

A: 90-100
B: 80-89.9
C: 70-79.9
D: 60-69.9
F: Below 60

Texts Materials, and Supplies

Understanding Hospital Billing and Coding, Debra P. Ferenc, Third Edition, Elsevier, Copyright 2014

Required Readings

Understanding Hospital Billing and Coding, Debra P. Ferenc, Third Edition, Elsevier, Copyright 2014

Other

Courses conducted via video conferencing may be recorded and shared for instructional purposes by the instructor.
For current texts and materials, use the following link to access bookstore listings: https://www.panolacollegestore.com.
For testing services, use the following link: https://www.panola.edu/student-services/studentsupport/academic-testing-center.
If any student in this class has special classroom or testing needs because of a physical learning or emotional condition, please contact the ADA Student Coordinator in Support Services located in the Charles C. Matthews Student Center or go to https://www.panola.edu/studentservices/student-support/disability-support-services for more information.
Withdrawing from a course is the student’s responsibility. Students who do not attend class and who do not withdraw will receive the grade earned for the course.
Student Handbook: https://www.panola.edu/ (located on at the bottom under student)

SCANS Criteria

Foundation skills are defined in three areas: basic skills, thinking skills, and personal qualities.
1. Basic Skills: A worker must read, write, perform arithmetic and mathematical operations, listen, and speak effectively. These skills include:
  1. Reading: locate, understand, and interpret written information in prose and in documents such as manuals, graphs, and schedules.
  2. Writing: communicate thoughts, ideas, information, and messages in writing, and create documents such as letters, directions, manuals, reports, graphs, and flow charts.
  3. Arithmetic and Mathematical Operations: perform basic computations and approach practical problems by choosing appropriately from a variety of mathematical techniques.
  4. Listening: receive, attend to, interpret, and respond to verbal messages and other cues.
  5. Speaking: Organize ideas and communicate orally.
2. Thinking Skills: A worker must think creatively, make decisions, solve problems, visualize, know how to learn, and reason effectively. These skills include:
  1. Creative Thinking: generate new ideas.
  2. Decision Making: specify goals and constraints, generate alternatives, consider risks, and evaluate and choose the best alternative.
  3. Problem Solving: recognize problems and devise and implement plan of action.
  4. Visualize ("Seeing Things in the Mind's Eye"): organize and process symbols, pictures, graphs, objects, and other information.
  5. Knowing How to Learn: use efficient learning techniques to acquire and apply new knowledge and skills.
  6. Reasoning: discover a rule or principle underlying the relationship between two or more objects and apply it when solving a problem.
3. Personal Qualities: A worker must display responsibility, self-esteem, sociability, self management, integrity, and honesty.
  1. Responsibility: exert a high level of effort and persevere toward goal attainment.
  2. Self-Esteem: believe in one's own self-worth and maintain a positive view of oneself.
  3. Sociability: demonstrate understanding, friendliness, adaptability, empathy, and politeness in group settings.
  4. Self-Management: assess oneself accurately, set personal goals, monitor progress, and exhibit self-control.
  5. Integrity and Honesty: choose ethical courses of action.
Workplace competencies are defined in five areas: resources, interpersonal skills, information, systems, and technology.
1. Resources: A worker must identify, organize, plan, and allocate resources effectively.
  1. Time: select goal-relevant activities, rank them, allocate time, and prepare and follow schedules.
  2. Money: Use or prepare budgets, make forecasts, keep records, and make adjustments to meet objectives.
  3. Material and Facilities: Acquire, store, allocate, and use materials or space efficiently. Examples: construct a decision timeline chart; use computer software to plan a project; prepare a budget; conduct a cost/benefits analysis; design an RFP process; write a job description; develop a staffing plan.
2. Interpersonal Skills: A worker must work with others effectively.
  1. Participate as a Member of a Team: contribute to group effort.
  2. Teach Others New Skills.
  3. Serve Clients/Customers: work to satisfy customer's expectations.
  4. Exercise Leadership: communicate ideas to justify position, persuade and convince others, responsibly challenge existing procedures and policies.
  5. Negotiate: work toward agreements involving exchange of resources, resolve divergent interests.
  6. Work with Diversity: work well with men and women from diverse backgrounds. Examples: collaborate with a group member to solve a problem; work through a group conflict situation, train a colleague; deal with a dissatisfied customer in person; select and use appropriate leadership styles; use effective delegation techniques; conduct an individual or team negotiation; demonstrate an understanding of how people from different cultural backgrounds might behave in various situations.
3. Information: A worker must be able to acquire and use information.
  1. Acquire and Evaluate Information.
  2. Organize and Maintain Information.
  3. Interpret and Communicate Information.
  4. Use Computers to Process Information. Examples: research and collect data from various sources; develop a form to collect data; develop an inventory record-keeping system; produce a report using graphics; make an oral presentation using various media; use on-line computer databases to research a report; use a computer spreadsheet to develop a budget.
4. Systems: A worker must understand complex interrelationships.
  1. Understand Systems: know how social, organizational, and technological systems work and operate effectively with them.
  2. Monitor and Correct Performance: distinguish trends, predict impacts on system operations, diagnose deviations in systems' performance and correct malfunctions.
  3. Improve or Design Systems: suggest modifications to existing systems and develop new or alternative systems to improve performance. Examples: draw and interpret an organizational chart; develop a monitoring process; choose a situation needing improvement, break it down, examine it, propose an improvement, and implement it.
5. Technology: A worker must be able to work with a variety of technologies.
  1. Select Technology: choose procedures, tools or equipment including computers and related technologies.
  2. Apply Technologies to Task: understand overall intent and proper procedures for setup and operation of equipment.
  3. Maintain and Troubleshoot Equipment: Prevent, identify, or solve problems with equipment, including computers and other technologies. Examples: read equipment descriptions and technical specifications to select equipment to meet needs; set up and assemble appropriate equipment from instructions; read and follow directions for troubleshooting and repairing equipment.