Content Outline and Competencies:

I. English Usage and the Rules of Proper Grammar, Punctuation and Style
   A. Apply the rules of spelling, including forming plurals and adjectives of English words.
   B. Define, spell and use English words commonly used in healthcare documentation.
   C. Recognize, correctly spell and use commonly misspelled English words.
   D. Recognize, correctly spell and use commonly misused English words.
   E. Recognize, correctly spell and use common English homophones (sound-alikes).
   F. Correctly assign the parts of speech (nouns, verbs, prepositions, etc.) to words in context.
   G. Use rules of correct grammar, including verb tense, subject-verb agreement and pronoun antecedent agreement.
   H. Apply the rules of punctuation to ensure clarity and accuracy of communication.

II. English and Medical Grammar and Style References
   A. Identify and use appropriate references and other resources.
   B. Evaluate and choose appropriate Internet references.

III. Medical Style as Defined by Healthcare Documentation Authorities
   A. Correctly use Arabic numerals, Roman numerals and units of measure as designated in the most recent edition of AHDI’s The Book of Style for Medical Transcription.
   B. Transcribe abbreviations, acronyms and brief forms in accordance with the most recent edition of AHDI’s The Book of Style for Medical Transcription.
   C. Recognize and appropriately transcribe, edit or flag jargon, slang, street talk, regionalisms, profanities, obscenities and vulgarities, in accordance with AHDI’s The Book of Style for Medical Transcription.
   D. Appropriately transcribe or translate foreign abbreviations and phrases, in accordance with AHDI’s The Book of Style for Medical Transcription.
   E. Correct syntax errors, avoiding dangling modifiers and awkward, unclear or humorous wording.

Content Outline and Competencies:

I. Medical Terminology, English Grammar, Punctuation and Spelling 
   A. Recall medical terminology and transcribe medical terms accurately in the appropriate context.
   B. Apply rules of the English language to produce professionally transcribed reports. 
   C. Utilize a keyboard to transcribe reports.

II. Dictation Patterns of Regional and Ethnic Dialects 
   A. Describe cultural competency and its relevance in healthcare.
   B. Listen to dictation from physicians who speak English as their first, as well as second language.

III. Terminology for Diseases and Medical Conditions
   A. Listen to dictation and identify described diseases and medical conditions.
   B. Transcribe terminology of diseases and medical conditions.

IV. Treatment Protocols for Diseases and Medical Conditions
   A. Listen to dictation and identify common treatment protocols for common diseases and medical conditions.
   B. Transcribe terminology of treatment protocols.
 
V. Proofreading and Editing Skills 
   A. Edit transcribed medical reports and identify formatting, grammar, punctuation and spelling errors.
   B. Correct errors found in transcribed reports.

VI. Inconsistencies and/or Inaccuracies in Dictation
   A. Listen to dictation and identify instances where physicians provide inconsistent, inaccurate or improbable documentation.
   B. Edit transcribed medical reports with inconsistencies and/or inaccuracies. 
   C. Compare dictation with transcribed documents to identify source of inconsistencies and/or inaccuracies.
   D. Describe ways by which healthcare documentation specialists can rectify inconsistencies and/or inaccuracies that result from physician dictation errors.

VII. Frequently Used Medical Terms
   A. Spell medical terms correctly when completing case studies and exercises.
   B. Spell medical terms correctly while transcribing medical reports.
   C. Define medical terms correctly when completing case studies and exercises.
   D. Define medical terms correctly that are located in medical reports.
   E. Apply medical terminology in the correct context when completing case studies and exercises.
   F. Apply medical terminology in the correct context when transcribing medical reports.

VIII. Reference Materials 
   A. Identify reference books commonly used by healthcare documentation specialists.
   B. Identify industry publications for healthcare documentation specialists.
   C. Identify websites of reference for healthcare documentation specialists.
   D. Discern credibility among reference materials published in print or on the Internet.

IX. Medical Reports Found in Health Records
   A. Correctly format the following types of reports: 
       1. History and physical report
       2. X-ray report/other imaging study reports
       3. Operative report
       4. Pathology report
       5. Discharge summary
       6. Consultation report
       7. Autopsy report

Content Outline and Competencies:

I. Identify Terminology for Diseases, Conditions and Treatment Protocols Related to the Following Medical Specialties
   A. Dermatology
   B. Ophthalmology
   C. Otorhinolaryngology
   D. Pulmonology
   E. Cardiology
   F. Gastroenterology 
   G. Obstetrics and gynecology
   H. Urology and nephrology
   I. Neurology
   J. Psychology
   K. Hematology and oncology
   L. Immunology

II. Identify Medical Reports Used in a Variety of Healthcare Settings
   A. Office notes
   B. Chart notes
   C. Consultation reports
   D. History and physical reports
   E. Operative reports
   F. Discharge summaries
   G. Radiology reports 
   H. Pathology reports
   I. Operative reports
   J. Labor and delivery reports
   K. Emergency department reports
   L. Neuropsychological evaluations
   M. Autopsy reports

III. Role of Speech Recognition Technology in Healthcare
   A. Describe the structure and function of back-end speech recognition.
   B. Describe the structure and function of front-end speech recognition.
   C. Describe the documentation functionality of speech recognition technology in electronic health records.

IV. Medical Reports Produced by Voice Recognition Technology
   A. Proofread reports produced by voice recognition technology.
   B. Correct document formatting errors in reports produced by voice recognition technology.
   C. Correct erroneous grammar, sentence structure, spelling and verbiage in medical reports produced by voice recognition technology.

V. Inconsistencies and/or Inaccuracies in Dictation
   A. Edit and revise inconsistencies and/or inaccuracies in transcribed reports while retaining the meaning of the dictation.

VI. Job Environment of Healthcare Documentation Specialists
   A. Describe the role and responsibilities of traditional medical transcriptionists.
   B. Describe the role and responsibilities of editors who ensure quality and accuracy in reports generated by speech recognition.
   C. Describe qualitative and quantitative reviews of healthcare documentation.
   D. Examine job opportunities for healthcare documentation specialists.
   E. Explore computerized systems that evaluate workflow, workload and productivity for healthcare documentation specialists who transcribe and edit medical reports.

VII. Credentialing Options for Healthcare Documentation Specialists
   A. Describe the Registered Medical Transcriptionist (RMT) credential offered by the Association for Healthcare Documentation Integrity. 
   B. Describe the Certified Medical Transcriptionist (CMT) credential offered by the Association for Healthcare Documentation Integrity.
   C. Review study material to prepare for the RMT credential.

VIII. Parameters for Amending Documentation in Electronic Health Records
   A. Describe the appropriate process for amending electronic health records.
   B. Describe the purpose of audit trails in electronic health records.

IX. Role of Healthcare Documentation Specialists in Ensuring Privacy and Security of Protected Health Information
   A. Identify applicable laws, regulation and statutes that relate to protecting health information.
   B. Describe appropriate instances when health information can be viewed or released without patient authorization. 
   C. Describe security measures used to protect paper and electronic health information.

Content Outline and Competencies:

I. Transcribe and/or Edit Authentic Clinician-Generated Documents 
   A. Students will apply correct English usage and the rules of proper grammar, punctuation and style and will use correct spelling and logical sentence structure.
   B. Students will evaluate the reliability of English and medical grammar and style references, as well as references for research and practice, and will apply information from selected references. 
   C. Students will differentiate among common drug classes, forms, dosages and routes of administration.
   D. Students will accurately transcribe/edit a minimum of 600 minutes (equivalent to 10 hours) of authentic clinician-generated documentation in an externship or simulated professional practice setting. 
   E. Students will apply correct ergonomic habits.

II. Medicolegal Concepts 
   A. Students will identify and analyze current trends and advancements in medicine.

III. Accuracy and Productivity
   A. Students will meet progressively demanding medical transcription/editing accuracy and productivity standards.
   B. Students will analyze their errors and devise corrective strategies.
 
IV. Professional Behavior and Ethical Conduct
   A. Students will appraise, and articulate an awareness of, the value of continuing education and professional credentials relevant to healthcare documentation practice.

V. References and Resources
   A. Students will apply correct medical style as defined by authorities such as AHDI’s The Book of Style and/or the AMA Manual of Style, especially rules that specifically apply to medical transcription/editing.

VI. Healthcare Documentation and Reimbursement 
   A. Students will understand general documentation concepts related to optimizing reimbursement.

Content Outline and Competencies:

I. History and Evolution of the Health Information Profession
   A. Describe the evolution of the health information profession.
   B. Describe how computerization has influenced health information management.
   C. Identify various credentials for health information professionals.
   D. Describe certification and educational requirements that prepare health information professionals for the healthcare workforce.

II. Purposes, Uses and Functions of the Health Record
   A. Describe principal and ancillary uses of the health record.
   B. Identify health record documentation as a necessary component for ensuring quality, safety and improvement in patient care.
   C. Explain the health record in terms of its status as a medicolegal document.

III. Content and Structure of the Health Record in Various Settings
   A. Describe the content and structure of health records in hospitals.
   B. Describe the content and structure of health records in ambulatory healthcare settings.
   C. Describe the content and structure of health records in long-term healthcare settings.
   D. Describe the content and structure of health records in home healthcare and hospice settings.
   E. Describe the content and structure of health records in behavioral healthcare settings.

IV. Healthcare Data Sets
   A. Describe the purpose and components of healthcare data sets.
   B. Identify healthcare data sets used in hospitals.
   C. Identify healthcare data sets used in ambulatory healthcare settings.
   D. Identify healthcare data sets used in long-term healthcare settings.
   E. Identify healthcare data sets used in home healthcare settings.
   F. Identify healthcare data sets used in behavioral healthcare settings.
   G. Identify healthcare data sets used for evaluating managed care plans.

V. Functions of Health Information Management
   A. Describe professional roles of health information professionals in healthcare organizations using paper-based health records.
   B. Describe professional roles of health information professionals in healthcare organizations using hybrid health records. 
   C. Describe current and anticipated roles of health information professionals in healthcare organizations using electronic health records.

VI. Healthcare Delivery Systems/Services 
   A. Summarize the healthcare delivery structure in the United States.
   B. Describe the role of the health record in healthcare settings.

VII. Compliance Standards in Health Record Documentation
   A. Identify regulatory and accrediting bodies that influence health record documentation practices in healthcare organizations.
   B. Describe the importance of documentation improvement programs for healthcare organizations.
   C. Describe the importance of ongoing record reviews in healthcare organizations.

VIII. Standards of Ethical Practice
   A. Recognize the American Health Information Management Association Code of Ethics as official ethical guidance for health information professionals in their daily work.
   B. Identify other ethical guidance related to specific job functions in health information management. 
   C. Apply ethical conduct in all educational and professional endeavors related to the management, use and storage of health information.

IX. Secondary Data Sources Used in Healthcare
   A. Identify types of registries and their role as secondary data sources in healthcare.
   B. Identify types of indices and their role as secondary data sources in healthcare.

X. Accreditation, Licensure or Certification
   A. Describe hospital licensure processes.
   B. Identify documentation standards related to the Medicare Conditions of Participation.
   C. Define "deemed status".
   D. Identify the role of the American Osteopathic Association and The Joint Commission in accrediting healthcare organizations.
   E. Describe accreditation bodies for ambulatory healthcare settings.
   F. Describe accreditation bodies for long-term healthcare settings.
   G. Describe accreditation bodies for behavioral healthcare settings.
   H. Identify the role of state surveyors in auditing healthcare organizations.
   I. Describe the uses of health record documentation in accreditation processes or other surveys conducted in healthcare organizations.

XI. Nomenclatures, Coding Classification Systems and Registries
   A. Describe the purpose of the Systemized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) in healthcare.
   B. Describe the uses of the International Classification of Diseases (ICD) coding classification systems in healthcare. 
   C. Describe the uses of the Current Procedural Terminology (CPT) coding classification system in healthcare.
   D. Describe the uses of the Healthcare Common Procedure Coding System (HCPCS) in healthcare.
   E. Describe the uses of the International Classification of Diseases Oncology (ICD-O) coding classification system in healthcare.
   F. Describe the uses of the Diagnostic and Statistical Manual of Mental Disorders (DSM) coding classification system in healthcare.
   G. Discuss the function of cancer registries in healthcare.
   H. Discuss the function of trauma registries in healthcare. 
   I. Describe the birth registration process in healthcare.

Content Outline and Competencies:

I. Electronic Health Records and Healthcare Delivery 
  A. Identify clinical and non-clinical uses of electronic health
records. 
  B. Describe functionalities of electronic health records that
influence patient care and safety, outcomes measurement, quality improvement
and administrative operations. 
  C. Navigate an electronic health record.
  
II. Electronic Health Record Adoption in the United States 
  A. Define meaningful use criteria in relation to uses of electronic
health records. 
  B. Describe the current health policy environment related to
meaningful use and electronic health record adoption. 
  C. Describe meaningful use criteria and their relation to
healthcare delivery. 
  D. Describe the role of Regional Extension Centers in electronic
health record adoption. 
  E. Discuss the importance of appropriate product selection and
effective implementation of electronic health records in healthcare
organizations. 
  F. Identify sources of barriers to electronic health record implementation. 
  G. Identify electronic health record products that have been
tested and certified by the Office of the National Coordinator Authorized
Testing and Certification Body. 
  H. Summarize the status of determining components of the legal
electronic health record. 
  I. Identify the role of health information management
professionals in e-Discovery of electronically stored information.
 
III. Health Information Exchange Activities 
  A. Identify the role of the Office of the National Coordinator for
Health Information Technology in health information exchange activities. 
  B. Discuss the role of health information exchange networks in
relation to patient care and health service delivery. 
  C. Define State Designated Entity as it relates to health
information exchange.  
  D. Identify the State Designated Entity for Kansas and Missouri.  
  E. Describe various challenges in the implementation of health
information exchange networks.  
  F. Identify various benefits to patient care as a result of
effective health information exchange activities.
 
IV. Health information systems 
  A. Identify types of health information systems.  
  B. Describe the importance of proper maintenance of master patient
indexes.  
  C. Describe the purpose of data dictionaries in health information
systems.  
  D. Describe the function of databases in a variety of information
systems used in healthcare.  
  E. Discuss the importance of data quality and its role in health
record documentation in electronic applications.  
  F. Summarize hardware and software used in the management of
health information.  
  G. Discuss privacy and security measures used to protect patient
information.  
  H. Describe the use of health information systems in specialized
areas of health information management such as medical coding, transcription,
cancer registry and release of information. 
  I. Analyze health record documentation with health information
systems.  

V. Encoder and Computer-Assisted Coding  
  A. Define encoder software.  
  B. Describe the uses of encoder software.  
  C. Navigate encoder software and use it to apply diagnosis and
procedure codes.  
  D. Locate coding resources built into encoder software.  
  E. Define computer-assisted coding.  
  F. Describe the uses of computer-assisted coding software.  
  G. Differentiate between computer-assisted coding platforms such
as natural language processing and structured input. 
  H. Navigate encoder software.  
  I. Discuss the emerging influence and future role of
computer-assisted coding software in medical coding. 
 
VI. Clinical Information Systems
  A. Identify types of clinical information systems.  
  B. Describe uses of clinical information systems in healthcare
organizations.  
  C. Identify clinical and non-clinical departments in healthcare
organizations whose operations are influenced by the use of clinical
information systems.  

VII. Administrative Information Systems 
  A. Identify types of administrative information systems used in
healthcare organizations.  
  B. Describe uses of administrative information systems in
healthcare organizations.  
  C. Identify clinical and non-clinical departments in healthcare
organizations whose operations are influenced by the use of administrative information
systems.  
  D. Simulate maintenance of a master patient index.  
  E. Describe the concept of enterprise master patient indices.  

VIII. Personal Health Records 
  A. Describe trends in the use of personal health records.  
  B. Identify consumer-specific challenges with personal health
records.  
  C. Identify barriers in the use of personal health records during
patient care encounters.  
  D. Identify privacy and security concerns related to personal health
records.

Content Outline and Competencies:

I. The Legal System in the United States
   A. Describe the purpose of the three branches of government in the United States.
   B. Identify the dual court system structure of the United States that includes Federal and
State courts.
   C. Describe the purpose of United States District Courts and United States Court of Appeals.
   D. Describe the purpose of the United States Supreme Court.
   E. Describe the role of States in structuring their court systems.
   F. Describe the role of Judges, Jurors, Prosecutors and Defense Lawyers in court cases.
   G. Describe the role of plaintiffs and defendants in court cases.

II. Health Records as Legal Documents
   A. Identify health records as “medico-legal” documents.
   B. Identify legal definitions of health records in paper-based, hybrid and electronic record environments.
   C. Define “discovery” and “e-discovery” and discuss how they relate to the use of health records in legal proceedings.
   D. Identify record retention policies in healthcare facilities and statutes that guide these policies.
   E. Identify appropriate responses to requests for health records from a variety of requestors.

III. Patient Rights and the Role Healthcare Professionals Play in Protecting These Rights
   A. Describe the evolution of patient rights guaranteed through legislative activities in the United States.
   B. Describe the responsibility of healthcare organizations in notifying patients of their guaranteed legal rights.
   C. Describe the responsibility of healthcare providers in providing services, medical care and treatment in a fashion that respects the rights of patients.

IV. Regulations Affecting Healthcare and Sensitive Health Records
   A. Identify Federal and State laws, statutes, and regulations intended to ensure privacy and security of health records and information therein.
   B. Identify specific considerations in Federal and State laws, statutes and regulations that pertain to the privacy of sensitive health information.
   C. Identify the right of patients to request restrictions on the uses and disclosures of sensitive health information.
   D. Identify Federal and State laws, statutes and regulations that protect human subjects who participate in medical research.
   E. Identify Federal and State laws, statutes and regulations that relate to privacy of health record documentation of alcohol and drug use.

V. Types of Consents
   A. Define “informed consent”.
   B. Differentiate between informed consent documents and the informed consent communication process.
   C. Describe necessary components within informed consent that ensure patient and provider communication addresses the risk and benefit considerations of medical treatment.
   D. Identify situations in which a patient is unable to consent to medical care or treatment.
   E. Identify situations in which a surrogate or proxy decision-maker renders healthcare decisions and informed consent for a patient unable to consent for themselves.
   F. Describe various types of advanced directives used in the determination of patient preferences related to medical care and treatment. 
   G. Identify situations in the use and disclosure of medical information that do and do not require patient consent.
   H. Describe the components of a HIPAA compliant release of medical information authorization form.

VI. Role of Health Professionals in the Legal Environment
   A. Identify responsibilities of healthcare professionals to provide care and service to patients that are most beneficial and reduce harm.
   B. Identify responsibilities of healthcare professionals to participate, as required by law, in legal proceedings or other inquiries. 
   C. Identify responsibilities of healthcare professionals to provide honest and accurate statements and testimony when required by legal inquiries or proceedings.
   D. Describe the role of professional liability insurance for healthcare professionals.

VII. Essential Elements for Establishing Negligence
   A. Identify criteria that must be met to demonstrate negligence in the care of a patient.
   B. Define “nonfeasance” and describe its role in negligent patient care.
   C. Define “misfeasance” and describe its role in negligent patient care.
   D. Define “malfeasance” and describe its role in negligent patient care.

VIII. Positions on Ethical Issues in Healthcare
   A. Identify bioethical dilemmas that occur in healthcare and medical research. 
   B. Describe principles of bioethics including autonomy, beneficence, nonmaleficence and justice.
   C. Examine societal debates related to bioethical issues.
   D. Describe the role of professional ethics for healthcare professionals.
   E. Describe the purpose and function of ethics committees in healthcare organizations.

IX. Legal and Ethical Issues Involving Electronic Health Records
   A. Describe the status of defining the legal electronic health record.
   B. Identify ethical and legal considerations of copy and paste functionality in electronic health records.
   C. Describe the role of audit trail capabilities in electronic health records.
   D. Identify privacy and security concerns related to electronic health records.

Content Outline and Competencies:

I. Structure and use of the volumes in ICD

A.     Explain the importance of and contents within the Alphabetic Index for diagnosis coding.
B.      Utilize the Alphabetic Index to guide diagnosis code selection.
C.      Explain the importance of and contents within the Tabular List of Diseases and Injuries.
D.      Explain the importance of and contents within the Alphabetic Index for procedure coding.
E.      Utilize the Alphabetic Index to guide procedure code selection.
F.      Explain the importance of and contents within PCS Tables.
G.      Compare and contrast the structure of and volumes in ICD-9-CM and ICD-10-CM/PCS.

II.     Correct coding conventions in ICD

A.     Recognize the Official Guidelines for Coding and Reporting as the authoritative guidance medical coding using the ICD coding classification system.
B.      Utilize instructional notes within ICD codebooks to guide code selection.

III.       Diagnosis coding according to current guidelines

A.     Identify and differentiate principal and secondary diagnoses as documented in health records.
B.      Assign ICD-10-CM codes for principal and secondary diagnoses.
C.      Assign ICD-9-CM codes for principal and secondary diagnoses.

IV.        Diagnosis code sequencing according to current guidelines

A.     Adhere to the Official Guidelines for Coding and Reporting when sequencing diagnosis codes for reporting purposes.

V. Procedure coding according to current guidelines

A.     Identify medical procedures used in the treatment of patients. 
B.      Assign ICD-10-PCS codes for procedures used to treat patients.
C.      Assign ICD-9-CM codes for procedures used to treat patients.

VI.        Procedure code sequencing according to current guidelines

A.     Adhere to the Official Guidelines for Coding and Reporting when sequencing procedure codes for reporting purposes.

VII.       Reference materials to facilitate code assignment

A.     Utilize coding reference materials to assist in the selection and sequencing of diagnosis and procedure codes.
B.      Identify authoritative published resources that provide clarification and education on medical coding.

VIII.      Official Guidelines for Coding and Reporting

A.     Identify the role of the Cooperating Parties in drafting and maintaining the Official Guidelines for Coding and Reporting.
B.      Utilize the Official Guidelines for Coding and Reporting to assist in proper code assignment and sequencing.

IX.        Discrepancies between coded data and documentation

a.     Recognize the importance of data quality in health records to support code assignment.
b.      Identify inappropriately assigned codes based on review of health record documentation.
c.      Recognize medical necessity as an indicator for appropriate code assignment.
d.      Identify situations that constitute initiation of a physician query. 

Content Outline and Competencies:

I. Use of the CPT manual
  A. Identify healthcare encounters that are coded with CPT codes for reimbursement.
  B. Identify healthcare settings that use CPT codes for generating reimbursement.
  C. Describe the purpose of Category I CPT codes for procedure and service coding.
  D. Describe the purpose of Category II CPT codes in performance measurement. 
  E. Describe the purpose of Category III CPT codes in tracking and reporting the use of emerging technologies.
  F. Identify the American Medical Association as the organization responsible for maintenance of and updates to the CPT coding classification system.

II. Use of the HCPCS manual
  A. Explain the relationship between Category I CPT codes and HCPCS Level I codes.
  B. Describe appropriate uses of HCPCS Level II codes in medical coding.
  C. Identify the Centers for Medicare & Medicaid Services as the government agency that maintains and updates the HCPCS coding classification system.

III. CPT symbols and section guidelines
  A. Describe the meaning of various symbols used in the CPT codebook which provide additional information about codes.
  B. Utilize instructional notes and guidance located at the beginning of sections in the CPT codebook to appropriately assign CPT codes.
  C. Utilize instructional notes and guidance located throughout the CPT codebook and assign codes in accordance with notes and guidance. 

IV. Body and ancillary systems coding
  A. Describe the purpose of the following sections in the CPT codebook: Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine.
  B. Assign CPT codes appropriately for anesthesia, surgery, radiology, pathology and laboratory, and medicine coding examples. 
  C. Identify, based on various sections of the CPT codebook and their respective rules, which qualified healthcare providers may report CPT codes to generate reimbursement.

V. Evaluation and Management codes
  A. Describe the use of the Evaluation and Management (E/M) section of codes in the CPT codebook.
  B. Identify appropriate situations for assigning E/M codes to generate reimbursement.
  C. Describe the Factors that influence E/M code assignment.
  D. Summarize the role of history, examination, and medical decision making in E/M code assignment.
  E. Summarize the role of counseling, coordination of care, presenting problems, and time in E/M code assignment.
  F. Describe documentation guidelines related to E/M code assignment. 
  G. Apply E/M codes to basic coding examples.

VI. Global procedures and bundled coding
  A. Identify the role of surgical packages in CPT/HCPCS coding for reimbursement purposes.
  B. Define “surgical package” as indicated by the CPT definition of surgical package.
  C. Define “surgical package” as indicated by the Medicare definition of surgical package.
  D. Define “unbundling” in the coding process.
  E. Apply CPT and Medicare guidelines related to surgical packages to avoid unbundling in the coding process.

VII. CPT/HCPCS modifiers
  A. Identify appropriate uses of modifiers in medical coding.
  B. Discuss the importance of modifiers in relation to accurate capture of information in the coding process.
  C. Discuss the importance of modifiers in relation to avoiding claims denials in the billing process.
  D. Apply CPT and HCPCS modifiers as appropriate to basic coding examples.
  E. Apply physical status modifiers as appropriate to basic coding examples.

VIII. HCPCS codes
  A. Assign HCPCS Level I codes (also known as CPT Category I codes) to basic coding examples.
  B. Assign HCPCS Level II codes to basic coding examples.

IX. Current issues regarding medical coding rules and regulations
  A. Identify current events in health policy that influence coding for outpatient and physician service reimbursement.
  B. Describe uses of CPT and HCPCS codes beyond reimbursement.
  C. Identify organizations and government agencies that are involved in providing updates and guidance related to the CPT and HCPCS coding classification systems.

X. CPT codes in relation to ICD diagnosis codes
  A. Describe the purpose of ICD diagnosis codes in identifying principal and secondary diagnoses documented in health records.
  B. Define “medical necessity”.
  C. Describe the role of ICD codes in supporting medical necessity for procedure and service coding and reimbursement.
  D. Describe general principles of health record documentation and their relevance to medical coding.

Content Outline and Competencies:

I. Health Record Data and Reimbursement
   A. Identify quality issues in health record documentation which leads to inappropriate code assignment. 
   B. Describe the influence of inappropriate code assignment on reimbursement. 
   C. Describe clinical documentation improvement efforts used to improve provider documentation and support the coding and reimbursement process.
 
II. Coding and Payment Methods in Reimbursement
   A. Describe coding classification systems used for reimbursement purposes.
   B. Describe the Inpatient Prospective Payment System used to reimburse inpatient hospitalizations. 
   C. Calculate diagnosis related groups for reimbursement of inpatient hospitalizations.
   D. Describe the Outpatient Prospective Payment System used to reimburse outpatient services and hospitalizations.
   E. Calculate ambulatory payment classifications for reimbursement of outpatient services and hospitalizations.
   F. Identify the influence of Resource Based Relative Value Scales on provider reimbursement.
   G. Describe the concept of value based purchasing and its influence on reimbursement.
   H. Identify proper bill forms used for submitting claims for various types of patient care settings.
   I. Explain the role of charge description master software in generating codes for reimbursement.
   J. Identify best practices related to charge description master maintenance.
   K. Identify unique circumstances in coding and reimbursement related to Critical Access Hospitals.
   L. Identify unique circumstances in coding and reimbursement related to Federally Qualified Health Centers.
   M. Identify emerging health policy initiatives that influence reimbursement methods.

III. Third-Party Reimbursement for Healthcare Services
   A. Describe Medicare eligibility criteria.
   B. Describe medical coverage provided by Medicare Parts A, B, C and D.
   C. Describe the purpose of Medicare supplemental insurance plans.
   D. Describe situations that require issuance of an advanced beneficiary notice to indicate non-coverage or potential non-coverage by the Medicare program.
   E. Describe Medicaid eligibility criteria.
   F. Describe medical coverage provided by Medicaid.
   G. Differentiate state and federal government roles in Medicaid funding and administration.
   H. Identify situations in which children are eligible for the Children’s Health Insurance Program.
   I. Describe Veteran and Military health insurance plans.
   J. Differentiate between Health Maintenance Organizations and Preferred Provider Organizations.
   K. Describe concepts of managed care and capitation in health insurance products.
   L. Analyze an explanation of benefits to determine insurance coverage for healthcare services.
   M. Describe factors that influence claims denial in the billing process.

IV. Significance of the Health Record in the Revenue Cycle
   A. Identify the health record as the source document for coding and reimbursement processing.
   B. Describe the importance of accurate health record documentation to achieve proper reimbursement.
   C. Describe the role of retrospective reviews of health record documentation in auditing the appropriateness of claims submitted for reimbursement.
 
V. Physician Query to Ensure Accurate Reimbursement
   A. Describe the role of physician queries in the coding process.
   B. Create an ethically appropriate physician query form. 
   C. Identify appropriate circumstances to initiate a physician query as a means to achieve appropriate coding and reimbursement.

VI. Coding Quality in Compliance
   A. Describe necessary components of coding compliance programs to ensure accuracy and appropriateness in medical coding. 
   B. Describe oversight activities performed by the government in relation to detecting fraud and abuse in coding and reimbursement. 
   C. Identify official references and resources to remain current on compliance topics.
   D. Describe the role of code editor software in detecting coding errors and preventing improper claim submissions.

VII. Various Auditing Methods
   A. Describe internal quality assurance activities in medical coding and billing departments.
   B. Describe the role of external auditors in assisting healthcare organizations with coding compliance.
   C. Describe the purpose of audits conducted by the government and associated contractors to enhance compliant coding and reimbursement.
   D. Identify emerging health policy initiatives that influence external auditing.

VIII. Legal and Ethical Dilemmas in Coding and Reimbursement
   A. Define “fraud” and “abuse” as they relate to healthcare reimbursement.
   B. Differentiate between fraud and abuse and identify how each is determined by the government.
   C. Identify monetary, civil and criminal penalties punishable for healthcare professionals found guilty of fraud and/or abuse.
   D. Identify types of unethical coding practices such as upcoding and unbundling.
 
IX. Health Policy Initiatives that Influence Reimbursement for Healthcare Services in the United States
   A. Identify Hospital Acquired Conditions and their relevance to coding and reimbursement in acute care hospitals.
   B. Describe the concept of Accountable Care Organizations.
   C. Describe the status of the Physician Quality Reporting Program.
   D. Identify changes in health policy that promote pay-for-performance.
   E. Describe how pay for performance may influence the future role of medical coders and other professionals involved in the healthcare revenue cycle.

X. Resources to Stay Current with Changing Reimbursement Practices
   A. Identify authoritative resources available to medical coders to provide continuing education and industry updates on medical coding and reimbursement.
   B. Describe emerging health policy initiatives in the United States that influence healthcare reimbursement and financing.

XI. Function and Purpose of Quality Improvement Organizations (QIOs)
   A. Describe the role of QIOs in protecting the Medicare Trust Fund and improving medical care provided to Medicare beneficiaries.
   B. Summarize the relationship between the Centers for Medicare & Medicaid Services and QIOs.
   C. Summarize the relationship between QIOs and healthcare providers and facilities.

Content Outline and Competencies:

I. Diagnosis Coding
   A. Assign International Classification of Diseases (ICD)-9-CM and ICD-10-CM codes for principal and secondary diagnoses.
   B. Sequence ICD-9-CM and ICD-10-CM codes in accordance with official coding guidance.
   C. Compare and contrast diagnosis code assignment from ICD-9-CM to ICD-10-CM.
   D. Identify the use of crosswalks and data mapping to facilitate conversion from ICD-9-CM to ICD-10-CM.

II. Procedure Coding 
   A. Assign ICD-9-CM and ICD-10-PCS codes for inpatient procedures for facility-based coding.
   B. Assign Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) codes for outpatient procedures for facility-based coding and physician services.
   C. Assign HCPCS Level II codes for physician services.
   D. Compare and contrast code assignment from ICD-9-CM to ICD-10-PCS.
   E. Identify the use of crosswalks and data mapping to facilitate conversion from ICD-9-CM to ICD-10-PCS.

III. Other Coding Classification Systems
   A. Describe the use of International Classification of Diseases-Oncology (ICD-O) in cancer reporting and surveillance.
   B. Describe the use of Diagnostic and Statistical Manual of Mental Disorders (DSM) in collecting and analyzing mental and behavioral healthcare data.
   C. Describe the use of National Drug Codes (NDCs) in identifying details about manufactured drugs recognized by the Food and Drug Administration.
   D. Describe the use of Current Dental Terminology (CDT) in claims submissions for dental service and procedure reimbursement.

Content Outline and Competencies:

I. Concepts of Pharmacology
   A. Describe various routes of administration of pharmacological agents.
   B. Describe absorption, distribution, metabolism and excretion as they relate to the medication cycle.
   C. Describe various categories of medications used in patient care.
   D. Define relevant pharmacology terms such as therapeutic effect, side effect, adverse effect, target organ, receptor, agonist, antagonist, synergism and antagonism.
   E. Identify the presence of generic and brand name medications available on the market.
   F. Apply correct spelling and pronunciation to medications.
   G. Identify uses of over-the-counter and prescription medications.

II. Government Regulation
   A. Describe the role of the Drug Enforcement Administration within the United States Department of Justice in relation to regulation of medications.
   B. Describe the role of the Food and Drug Administration within the United States Department of Health and Human Services in relation to regulation of medications.
   C. Define the term controlled substance.
   D. Identify laws related to controlled substances.
   E. Explain the role of clinical trials in ensuring safety and effectiveness of medications.

III. Ethical Considerations
   A. Define cultural competency as it relates to patient care.
   B. Identify how cultural norms influence personal preferences in taking medications.
   C. Describe societal debates on the benefit and harm of vaccinations.
   D. Identify commonly administered vaccinations.

IV. Central Nervous System
   A. Identify common medical conditions and diseases associated with the central nervous system.
   B. Recognize medications used in the treatment of common medical conditions and diseases of the central nervous system.
   C. Summarize the mechanism of action among commonly prescribed and over-the-counter medications used to treat common medical conditions and diseases of the central nervous system.

V. Respiratory System 
   A. Identify common medical conditions and diseases associated with the respiratory system.
   B. Recognize medications used in the treatment of common medical conditions and diseases of the respiratory system.
   C. Identify various types of devices used to administer inhaled pharmaceutical agents in the treatment of common medical conditions and diseases of the respiratory system.
   D. Summarize the mechanism of action among commonly prescribed and over-the-counter medications used to treat common medical conditions and diseases of the respiratory system.

VI. Gastrointestinal System 
   A. Identify common medical conditions and diseases associated with the gastrointestinal system.
   B. Recognize medications used in the treatment of common medical conditions and diseases of the gastrointestinal system.
   C. Summarize the mechanism of action among commonly prescribed and over-the-counter
medications used to treat common medical conditions and diseases of the gastrointestinal system.

VII. Genitourinary System 
   A. Identify common medical conditions and diseases associated with the genitourinary system.
   B. Recognize medications used in the treatment of common medical conditions and diseases of the genitourinary system.
   C. Summarize the mechanism of action among commonly prescribed and over-the-counter medications used to treat common medical conditions and diseases of the genitourinary system.

VIII. Cardiovascular System 
   A. Identify common medical conditions and diseases associated with the cardiovascular system.
   B. Recognize medications used in the treatment of common medical conditions and diseases of the cardiovascular system.
   C. Summarize the mechanism of action among commonly prescribed and over-the-counter medications used to treat common medical conditions and diseases of the cardiovascular system.

IX. Endocrine System 
   A. Identify common medical conditions and diseases associated with the endocrine system.
   B. Recognize medications used in the treatment of common medical conditions and diseases of the endocrine system.
   C. Summarize the mechanism of action among commonly prescribed and over-the-counter medications used to treat common medical conditions and diseases of the endocrine system.

X. Integumentary System 
   A. Identify common medical conditions and diseases associated with the integumentary system.
   B. Recognize medications used in the treatment of common medical conditions and diseases of the integumentary system.
   C. Summarize the mechanism of action among commonly prescribed and over-the-counter medications used to treat common medical conditions and diseases of the integumentary system.

XI. Antineoplastic Medications 
   A. Describe the use of chemotherapy in cancer treatment.
   B. Recognize pharmaceutical products classified as antineoplastic agents used in the treatment of various cancers.

XII. Total Parenteral Nutrition 
   A. Define total parenteral nutrition.
   B. Recognize administration methods of total parenteral nutrition.
   C. Identify common medical conditions that may require the use of total parenteral nutrition.

XIII. Vitamins, Herbs and Supplements
   A. Identify prescribed and over-the-counter uses of common vitamins, herbs and supplements.

Content Outline and Competencies:

I. Determine Significant Patient Diagnoses and Procedures
   A. Review health record data to determine diagnoses required for coding and reporting for reimbursement.
   B. Review health record data to determine procedures for coding and reporting for reimbursement.
 
II. Diagnosis and Procedure Coding 
   A. Assign diagnosis codes using the current version of the International Classification of Diseases coding classification system.
   B. Assign procedure codes using the current version of the Current Procedural Terminology coding classification system.
   C. Assign procedure codes using the current version of the International Classification of Diseases coding classification system.
   D. Assign Present on Admission indicators as needed to identify hospital acquired conditions that must be reported for reimbursement purposes.
   E. Review codes assigned to patient accounts with internship supervisor or other designated department employee.
   F. Utilize code editor software to assess accuracy and validity of assigned codes when applicable.
   G. Adhere to published coding guidelines in the Official Guidelines for Coding and Reporting to appropriately sequence diagnosis and procedure codes.
   H. Utilize instructional notes within coding manuals to assist in appropriate sequencing of diagnosis and procedure codes.
   I. Review health record documentation to ensure that code assignment is supported by appropriate
clinical data and information provided by physicians or other qualified healthcare professionals.
   J. Identify ambiguous or missing data in health records and initiate a physician query to ensure
proper code assignment when appropriate.

III. Interactions 
   A. Tour hospital or clinic departments. 
   B. Interview personnel whose work relates to medical coding.