Medical Coding and Biling 1&2

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Timings : Friday 8:00 AM - 11:00 AM
Duration : 10 Weeks
Fee : QAR 500.00
Uniform : QAR 30.00

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INTRODUCTION

Clinical Coding ranks as one of the most promising careers around the world. In fact, it is now considered a high-demand profession and the role of coders has become more important than ever. Clinical Coding involves reviewing, analyzing, and translating medical information from a patient’s health record into alphanumeric/numeric codes, using a complex health classification system. The resulting data provides comprehensive quality information that is used for direct patient care, physician and hospital reimbursement, research, decision making and health system planning. The future clinical coders will have twice the opportunity to make a difference and shoulder twice the responsibility that they do today. The plan is to fill the gap by candidates who are not only talented and skilled, but also ethical.


COURSE OBJECTIVES

By the end of this course, the student will be able to:

  1. Identify the structure and organization of the five volumes of ICD-10-AM, ACHI and ACS.
  2. Interpret the conventions and instructions used in ICD-10-AM, ACHI and ACS.
  3. Apply the Australian Coding Standards.
  4. Examine health record structure, principles, language of clinical practice and diseases/conditions/diagnoses and medical treatments in simple to moderate cases.
  5. Extract relevant clinical information from medical records.
  6. Identify principal diagnosis and principal procedure for an admission as well as additional diagnoses and additional procedures.
  7. Select accurate codes from ICD-10-AM, ACHI and ACS for diseases, conditions, injuries, and procedures.

CODER COMPETENCIES

After finishing the clinical coding program, coders must be able to achieve the following:

  1. Work effectively in the healthcare system
  2. Extract clinical information to support coding
  3. Prepare to work as clinical coder
  4. Assign codes to an episode of care
  5. Ensure quality of coded data
  6. Manage time, resources, and professional development (Internship)
  7. Comply with workplace policies, procedures, and professional requirements (Internship)
  8. Maintain confidentiality of medical records and client information at all times.

TRAINING DELIVERY MODE

Face-to-Face: to obtain an understanding of basic concepts that are required to undertake further study (Elaborated lectures/ discussion and activities for each Chapters/Topic will be prepared).

Self-Directed Learning (e.g. Assignments from textbooks and online materials): to reinforce/strengthen students understanding of the coding conventions, standards and practices.

Internship: by reviewing records and practicing coding at a hospital setting under direct supervision of assigned mentor.

Blended/Flexible Model: Combine classroom learning with online learning (optional for distance learning)

Students will be able to:

    1. Demonstrate academic integrity and honesty.
    2. Attend and participate in classes and seminars, prepared and on time.
    3. Complete the assigned work in a timely manner with attention to quality of work.
    4. Communicate in a careful and respectful manner with instructors, peers, and other members of the program.
    5. participate as an engaged learner and submit assignments as per instructed deadline.
    6. Act in a civil manner that respects the college level learning/social environment and complies with program policies outlined in the student and program manual.
    7. Utilize program resources and seek help when needed.
    8. Respect diverse ideas and opinions. Identify, develop, and implement a plan to achieve their educational goals.

EVALUATION AND ASSESSMENT

The evaluation should be done as following:

  1. Assessments:
  • After finishing each Chapters, students should undertake assessment. The educator should monitor the student’s progress through these assessments. Educator provide the student with feedback where appropriate.
  • Assessments should include: Case Studies, Discharge Summaries, and Medical Records.
  1. Internship:

Internship is for practice coding a medical record in a hospital setting. Student will be evaluated for:

  • the number of episodes per specialty
  • 80% Correct assignment for the following:
    • Principle diagnosis.
    • Additional diagnoses.
    • Sequence of codes.
  1. Final exam: Theory and Practical with a passing score of 80% or higher.

COURSE PASSING REQUIREMENTS & GRADING SYSTEM
  1. Attendance and Attitude 10%
  2. Frequent Quizzes 10%
  3. Chapter Assessments 50%
  4. Internship 30%
  5. Total Passing Score for the Course is 80%

MARKING FOR MEDICAL TERMINOLOGY:
  1. Assessment for medical terminology and basic Anatomy and Physiology will be defined by the Instructor.
  2. Students must pass and understand the medical terminology and Basic anatomy and Physiology assessments to be eligible for taking the coding internship.
  3. Passing score for the medical Terminology Examination is 80%.

Note: upon completing course requirement, students will receive certificate of program completion and/or graduation certificate.


FINAL ASSESSMENT FOR MEDICAL TERMINOLOGY/ANATOMY AND PHYSIOLOGY:

Each student will complete a two (2) hour examination with seven (7) questions, combination of true or false, fill in the blanks and definition of medical terminologies with a full mark of a 100. Passing score is 80%.

Final Assessment for Clinical Coding Part 1:   Each student will be given two (2) hours to complete 10 case studies, 2 Discharge summaries and 1 medical record for the final Assessment in Part 1 Coding. Passing Score is 80%.

Final Examination in Clinical Coding Part 2:  Each student will complete a three (3) hour examination for theory Coding guidelines and Australian Coding Standards (Closed book). And a three-part practical examination consisting of five (5) case studies, Three (3) discharge summaries and two (2) Medical records coding, using the ICD-10-AM/ACHI/ACS. Passing score is 80%.

Discussion of each Chapter/Topic will be at least an hour depending on the complexity of the subject and on the students understanding capabilities.

Students are required to self-study at least five (5) hours per week to be able to complete assignments given at the end of the class.


CLINICAL CODING PART 1

Week

Topic

Assessment

Total Credit Hours

1

Introduction to Health Information Management/ Clinical Coding

Lecture/Exercises

3 hours

2

Medical Terminology and Basic Anatomy and Physiology

Lecture/Exercises/Assessments

3 hours

3

Coding Diagnoses with ICD 10 AM/ Coding Procedures with ACHI/Australian Coding standards/Coding from medical records

Lecture/Exercises

3 hours

4

Factors influencing health status/Symptoms, Signs and abnormal clinical findings/Certain infectious and parasitic diseases

Lecture/Exercises

3 hours

5

Neoplasms/Diseases of blood and immune mechanism

Lecture/Exercises

3 hours

6

Endocrine, nutritional and metabolic diseases/Mental and behavioural disorders/Diseases of Nervous System

Lecture/Exercises

3 hours

7

Diseases of the eye and adnexa/Diseases of ear and mastoid process/Diseases of circulatory system/Diseases of respiratory system

Lecture/Exercises

3 hours

8

Diseases of digestive system/Diseases of the skin and subcutaneous tissue/Diseases of musculoskeletal system/Diseases of genitourinary system

Lecture/Exercises

3 hours

9

Pregnancy, childbirth and the puerperium/Conditions originating in the perinatal period/Congenital malformations and deformations/Injury and external Causes of injury/Poisoning and external causes of poisoning.

Lecture/Exercises

3 hours

10

Assessments/Exam

(Coding/Medical Terminology/anatomy and Physiology

Final Exams

4 hours


CLINICAL CODING PART 2

Week

Topic

Assessment

Total Credit Hours

1

Assessments and Medical Records Coding

Exercises

3 hours

2

Assessments and Medical Records Coding

Exercises

3 hours

3

Assessments and Medical Records Coding

Exercises

3 hours

4

Assessments and Medical Records Coding

Exercises

3 hours

5

Assessments and Medical Records Coding

Exercises

3 hours

6

Internship

-

3 hours

7

Internship

-

3 hours

8

Internship

-

3 hours

9

Internship

-

3 hours

10

Final Examinations for Theory and Practical Coding

 

3 hours

 

End

   

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