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Business and Information Technology Education
Diagnosis Coding
This course introduces the basic principles and conventions of the International Classification of Diseases (ICD). It simulates the application of coding principles with examples and exercises based on actual case documentation.
Jaimee Sizemore
Instructional Coordinator
Ph: (918) 828-5093
Foundations of Medical Office Assistant/Medical Terminology, Medical Insurance, and Patient Billing
A. Reimbursement, HIPAA, and Compliance
1. Distinguish among Medicare Part A, B, C, and D.
2. Interpret rules of the Health Insurance Portability and Accountability Act (HIPAA).
3. Locate information in the Federal Register.
4. Explain the RBRVS system.
5. Understand the framework of Medicare Fraud programs.
6. Identify the major components of Managed Health Care

B. Overview of ICD-10-CM.
1. Explain the development of the ICD-10-CM.
2. Describe how the ICD-10-CM replaces the ICD-9-CM, Volumes 1 and 2.
3. Identify the improvements in the ICD-10-CM.
4. List the official instructional notations in ICD-10-CM.
5. Describe the format of ICD-10-CM.

C. ICD-10-CM Outpatient Coding and Reporting Guidelines.
1. Identify a first-listed diagnosis.
2. Define assignment of codes for unconfirmed diagnosis.
3. Describe code assignment for outpatient surgery.
4. Outline assignment of additional diagnoses.
5. Describe Z code reporting.
6. Define observation stay.
7. Delineate the differences between first-listed and coexisting conditions.
8. Explain uncertain diagnosis.
9. Understand assignment of codes for chronic diseases.
10. Recognize diagnostic services.
11. Recognize therapeutic services.
12. Illustrate reporting of preoperative evaluations.
13. Explain prenatal visits.
14. Apply the Official Guidelines for Coding and Reporting

D. Using ICD-10-CM.
1. Demonstrate ability to utilize the Alphabetic Index and Tabular List.
2. Understand the steps to accurate coding.
3. Comprehend the organization of the Guidelines.
4. Use both the Alphabetic Index and Tabular List.
5. Outline the need for level of specificity in diagnosis coding.
6. Identify conditions integral to a disease process.
7. Assign multiple codes to a single condition.
8. Report acute and chronic conditions.
9. Demonstrate application of combination codes.
10. Differentiate between residual and late effects.
11. Abstract information that determines if a condition is impending or threatened.
12. Outline the rules when reporting the same diagnosis code more than once.
13. Assign codes based on laterality.

E. Chapter-Specific Guidelines (ICD-10-CM Chapters 1-10).
1. Review certain infectious and parasitic disease codes.
2. Analyze neoplasm codes.
3. Assess the blood and blood-forming organs and certain disorders involving the immune mechanism codes.
4. Examine the endocrine, nutritional, and metabolic diseases codes.
5. Understand the mental, behavioral and neurodevelopmental disorder codes.
6. Examine the diseases of the nervous system codes.
7. Analyze the diseases of the eye and adnexa codes.
8. Comprehend the organization and reporting of the ear and mastoid process codes.
9. Recognize the diseases of the circulatory system codes.
10. Evaluate the diseases of the respiratory system codes.
11. Demonstrate the ability to report diagnoses with I-10 codes for Chapters 1-10

F. Chapter-Specific Guidelines (ICD-10-CM Chapters 11-14).
1. Examine the digestive system coding.
2. Review coding the skin and subcutaneous tissue diseases.
3. Understand diseases of the musculoskeletal system and connective tissue coding

G. Chapter-Specific Guidelines (ICD-10-CM Chapters 15-21).
1. Review the pregnancy, childbirth, and puerperium coding.
2. Report services of certain conditions originating in the perinatal period.
3. Examine the congenital malformations, deformities, and chromosomal abnormalities.
4. Define the rules of symptoms, signs, and abnormal clinical and laboratory findings that are not elsewhere classified.
5. Identify the elements of coding injury, poisonings, and certain other consequences of external causes.
The class will primarily be taught by the lecture and demonstration method and supported by various media materials to address various learning styles. There will be question and answer sessions over material covered in lecture and media presentations. Supervised lab time is provided for students to complete required projects. Students are graded on theory and shop practice and performance.
ICD-9 and ICD-10
Academy Academy of Professional Coders (AAPC)
Step-by-Step 2015 Text and Workbook, by Buck, Elsevier Publishing (2015)
2016 ICD-10-CM Profession Edition, 1st Edition, by Buck, Elsevier Publishing
2016 Current Procedural Terminology, Professional Edition, AMA Publishing
2016 HCPCS Level II, Professional Edition, AMA Publishing
*Coding manuals ae updated annually and correspond to the current year.
Various supplemental materials.
Career Majors That Sequence This Course
Career Cluster Pathway Career Major
Business Management & Administration Business Information Management Medical Coding