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Medical & Healthcare Programs ►Medical Inpatient Auditing




Overview

Developed to provide an advanced look into the world of medical coding and auditing, our Medical Inpatient Auditing course explores essential applications and real patient cases that explain coding services. Hands-on physician documentation is provided to help develop essential auditing knowledge and skills. Our course is divided into chapters that cover ICD-10-CM, CPT, and HCPCS. We explore codes for evaluation and management services, medicine, radiology, pathology and laboratory, surgeries, and anesthesia.

This Program Includes:

  • Medical Inpatient Auditing
  • Medical Coding
  • Medical Terminology
  • Human Anatomy

After completing this course, you should be able to:

  • Identify types of service and diagnosis codes, how to use modifiers, and how to use the auditform
  • Recognize the key components of E/M and medicine coding
  • Recall terminology for positions and placements and types of services for radiology, pathology, and laboratory
  • Describe coding aspects for surgical procedures and body systems
  • Identify base units and modifiers related to coding for anesthesia
  • Identify the core elements of the ICD-10-CM coding system
  • Recognize the conventions and guidelines of the ICD-10-CM coding system
  • List the conventions and guidelines of the HCPCS coding system
  • Define the fundamental uses and guidelines of the CPT coding system
  • Recall the use of modifiers and evaluation and management services (E/M)
  • Identify how to gain and understand the basic word structure in medical terminology
  • Recognize how to relate the medical terms to the structure and function of the human body
  • Identify body systems, body cavities, and planes of the body
  • Define words by dividing them into their component parts
  • Recall the terminology used with medical specialists and case reports
  • Define the basic anatomical terminology of the human body
  • Recall the spine and trunk regions of the human body and their functions
  • Recognize the thorax and the abdominal sections of the human body
  • Identify the functions of the pelvis and lower limbs region of the body


Medical Inpatient Auditing Module 1

Evaluation and Management Service

  • Hospital Inpatient Services
  • Diagnosis Coding
  • Consultations and Discharging
  • Office and Other Outpatient Services
  • Hospital Observation Services
  • Neonatal and Newborn Services
  • Preventive Medicine Services

Medical Inpatient Auditing Module 2

Medicine

  • Vaccinations and Immunizations
  • Psychiatry
  • Dialysis
  • Vascular Diagnostic Studies
  • Central Nervous System Tests
  • Chemotherapy
  • Physical Medicine and Rehabilitation
  • Medical Nutrition Therapy
  • Special Services, Procedures, and Reports

Medical Inpatient Auditing Module 3

Radiology, Pathology, and Laboratory

  • Interventional Radiology
  • Diagnostic Radiology
  • CAT/CT Scans
  • Ultrasound
  • Radiation Oncology
  • Urinalysis, Molecular Pathology, and Chemistry
  • Hematology and Coagulation
  • Immunology
  • Transfusions
  • Microbiology
  • Surgical Pathology

Medical Inpatient Auditing Module 4

Integumentary

  • Debridement
  • Lesion Excision
  • Skin Tags
  • Nails
  • Skin Grafts
  • Pressure Ulcers
  • Breast Procedures

Medical Inpatient Auditing Module 5

Cardiovascular

  • Arteriosclerosis
  • Coronary Artery Bypass Grafts
  • Pacemaker
  • Stress Tests
  • Myocardial Perfusion Scan
  • Cardiac Catheterization

Medical Inpatient Auditing Module 6

Digestive and Hemic/Lymphatic Systems

  • Intestinal Obstruction
  • Hemorrhoids
  • Catheters
  • Endoscopy Procedures
  • Gastritis
  • Ulcer
  • Hernia
  • Polyps
  • Laparoscopic Procedures
  • Cholecystectomy
  • Crohn’s Disease

Medical Inpatient Auditing Module 7

Musculoskeletal System

  • Arthrocentesis
  • Fixation
  • Excision
  • Repair, Revision, and Reconstruction
  • Sprains and Strains
  • Fractures
  • Amputation
  • Arthroscopy

Medical Inpatient Auditing Module 8

Respiratory

  • Enzyme Immunoassay
  • Spirometry
  • Sleep Studies
  • Symptoms, Signs, and ill-Defined Conditions
  • Symptoms as Diagnoses
  • Pulmonary Stress Test
  • Septoplasty and Turbinate
  • Thoracentesis
  • Tracheostomy

Medical Inpatient Auditing Module 9

Urinary, Reproductive and Genital Systems

  • Urinary System
  • Male Genital System
  • Vasectomy
  • Reproductive System Procedures
  • Male and Female Genital Systems
  • Maternity Care and Delivery

Medical Inpatient Auditing Module 10

Nervous, Eye, and Auditory Systems

  • Craniotomy
  • Subdural Hematoma
  • Stealth Surgery
  • Cranioplasty
  • Shunts
  • Eye Examinations
  • Cataracts
  • Photocoagulation
  • Ectropion and Entropion
  • Epiphora
  • Office Services
  • Myringotomy and Tympanostomy

Medical Inpatient Auditing Module 11

Anesthesia

  • Types of Anesthesia
  • Base Units
  • Positioning
  • Anesthesia Time
  • Pain Management
  • Obstetrics
  • Critical Care
  • Patient-Controlled Analgesia

Medical Coding Module 1

Overview of ICD-10-CM

  • Reimbursement, HIPAA and Compliance
  • Basic Structure of the Medicare Program
  • Improvements to the ICD-10-CM
  • ICD-10-CM Format
  • Mapping
  • Outpatient Coding and Reporting Guidelines
  • Unconfirmed Diagnosis
  • Z Codes
  • Chronic Diseases
  • Therapeutic Services

Medical Coding Module 2

Using ICD-10-CM

  • Accurate Coding
  • Alphabetic Index and Tabular List
  • Level of Specificity
  • Integral Conditions
  • Multiple Coding
  • Chapter Specific Guidelines Chapters 1-10
  • Endocrine, Nutritional and Metabolic Diseases
  • Diseases of the Nervous System
  • Diseases of the Circulatory System
  • Diseases of the Respiratory System

Medical Coding Module 3

Chapter-Specific Guidelines

  • Diseases of the Digestive System
  • Diseases of the Skin and Subcutaneous Tissue
  • Diseases of the Musculoskeletal System and Connective Tissue
  • Pregnancy, Childbirth and Puerperium
  • Congenital Malformations, Deformations and Chromosomal Abnormalities
  • Symptoms, Signs and Abnormal Clinical and Laboratory Findings
  • Injury and Poisoning

Medical Coding Module 4

CPT, HCPCS and Modifiers

  • The Purpose of the CPT Manual
  • Updating the CPT Manual
  • CPT Manual Format
  • Level II National Codes (HCPCS)
  • History of National Level Codes
  • Updating the HCPCS Manual
  • National Physician Fee Schedule
  • CPT Modifiers

Medical Coding Module 5

E/M Services and Anesthesia

  • Contents of the E/M Section
  • Three Factors of E/M Codes
  • Various Levels of E/M Service
  • An E/M Code Example
  • Using the E/M Codes
  • Documentation Guidelines
  • Types of Anesthesia
  • Anesthesia Section Format
  • Formula for Anesthesia Payment
  • Concurrent Modifiers

Medical Coding Module 6

Surgery Guidelines and Integumentary System

  • Surgery Section
  • Notes and Guidelines
  • Special Reports
  • Separate Procedure
  • Surgical Package
  • Skin, Subcutaneous and Accessory Structures
  • Burns
  • Destruction
  • Breast Procedures

Medical Coding Module 7

Musculoskeletal and Respiratory Systems

  • Fractures and Dislocations
  • Application of Casts and Strapping
  • Endoscopy
  • Arthroscopy
  • Accessory Sinuses
  • Larynx
  • Trachea
  • Bronchi Lungs and Pleura

Medical Coding Module 8

Cardiovascular, Hemic, Lymphatic and Digestive Systems

  • Cardiovascular Coding in the Surgery Section
  • Cardiovascular Coding in the Medicine Section
  • Cardiovascular Coding in the Radiology Section
  • Hemic and Lymphatic Systems
  • Mediastinum and Diaphragm
  • Lips
  • Vestibule of Mouth
  • Salivary Glands and Ducts
  • Pharynx, Adenoids and Tonsils
  • Intestines

Medical Coding Module 9

Urinary, Reproductive and Genital Systems

  • Urinary System
  • Male Genital System
  • Intersex Surgery
  • Reproductive System Procedures
  • Male and Female Genital Systems
  • Maternity Care and Delivery

Medical Coding Module 10

Endocrine System, Eye, Ocular Adnexa and Radiology

  • Nervous System
  • Auditory System
  • Operating Microscope
  • Radiology Terminology
  • Diagnostic Radiology
  • Breast Mammography
  • Diagnostic Ultrasound
  • Radiation Oncology

Medical Coding Module 11

Pathology/Laboratory, Medicine and Inpatient Coding

  • Organ or Disease Oriented Panels
  • Therapeutic Drug Assays
  • Urinalysis, Molecular Pathology and Chemistry
  • Immunizations
  • Gastroenterology
  • Allergy and Clinical Immunology
  • Medical Nutrition Therapy
  • Medication Therapy Management Services
  • Differences between Inpatient and Outpatient Coding
  • Present on Admission (POA)

Medical Terminology Module 1

Basic Word Structure

  • Word Analysis
  • Combining Forms
  • Suffixes & Prefixes
  • Pronunciation of Terms
  • Exercises & Applications

Medical Terminology Module 2

Organization of the Body

  • Body Systems and Cavities
  • Divisions of the Back
  • Planes of the Body
  • Pronunciation of Terms
  • Exercises & Applications

Medical Terminology Module 3

Suffixes

  • Introduction to Suffixes
  • Suffixes and Terminology
  • Diagnostic & Procedural Suffixes
  • Pronunciation of Terms
  • Exercises & Applications

Medical Terminology Module 4

Prefixes

  • Combining Forms & Prefixes
  • Prefixes and Terminology
  • Define Common Prefixes
  • Pronunciation of Terms
  • Exercises & Applications

Medical Terminology Module 5

Medical Specialists & Case Reports

  • Medical Specialists
  • Combining Forms & Vocabulary
  • Case Reports & Terminology
  • Pronunciation of Terms
  • Exercises & Applications

Medical Terminology Module 6

Body Systems –Part 1

  • Cardiovascular System
  • Digestive System
  • Endocrine System
  • Female Reproductive System
  • Lymphatic System

Medical Terminology Module 7

Body Systems –Part 2

  • Male Reproductive System
  • Musculoskeletal System
  • Nervous System
  • Respiratory System
  • Skin & Sense Organs
  • Urinary System

Human Anatomy Module 1

Terminology and the Head and Neck Region

Module one begins with an introduction of the study of movement and muscles. Beginning with basic anatomical terminology, module one reveals the meaning in a standard anatomical position.Also included inthis module is the study of musculoskeletal anatomy, the main focus is on muscles and the bones to which they attach. Finally, included in module one, is a study of the head and neck regions of the human body.

  • Anatomical Terminology
  • Bones, Muscles, and Joints
  • The Skull
  • Base of the Skull and Its Attachments
  • Muscles of the Face and Jaw
  • Suspensory Muscles of the Larnyx
  • The Tongue
  • Muscles of the Palate
  • Muscles of the Throat
  • The Larynx

Human Anatomy Module 2

The Spine and Trunk Region

Module two covers the spine and truck regions of the human body, beginning with the anterior muscles of the cervical spine.Moving on, we will take a close examination of the vertebrae of the spine, which forms the central support structure for the body.After learning more about the spine, the study moves on with the supporting ligaments of the spine, and the muscles groups of the back and the layers connecting the pieces together

  • Anterior Muscles of the Cervical Spine
  • The Vertebrae of the Spine
  • The Spine and Its Supporting Ligaments
  • Muscles of the Back: Deep Layers
  • Muscles of the Back: Middle and Superficial Layers
  • Muscles Attaching to the Front of the Spine

Human Anatomy Module 3

The Thorax, Abdomen, Shoulder Girdle and Upper Limb

Module three examines the thoraxand the abdomen sections of the human body.Beginning with the thorax and muscles of respiration, the module will continue on to learn more about the muscles of the abdomen and compare them to the muscles of the back. The rib cage as a whole is supportedby various muscles.Module three will carefully examine each of these suspensory muscle groups.Also included in module three is the anatomy of the shoulder girdle and upper limbs.We will study the muscles of the arm and shoulder, forearm, hand, and wrist.

  • The Thorax and Muscles of Respiration
  • The Abdominal Muscles
  • Suspensory Muscles of the thorax
  • The Spiral Musculature of the Trunk
  • The Shoulder Girdle
  • Muscles of the Arm and Shoulder
  • Muscles of the Forearm
  • Muscles of the Hand and Wrist
  • Intrinsic Muscles of the Hand

Human Anatomy Module 4

The Pelvis and Lower Limb

Module four takes a look at the pelvis and lower limb.Beginning with the pelvic girdle, the study will move on to the muscles of the pelvis and hip.The pelvis plays a crucial role in posture and movement and it is important to learn about the support structure for the legs. The muscles of the upper leg and their groups and purpose will be examined in module four, as well as, the knee, lower leg, and ankle. Finally examined inmodule four is the muscles of the foot.

  • The Pelvic Girdle
  • Muscles of the Pelvis and Hip
  • Muscles of the Thigh
  • The Knee, Lower Leg, and Ankle
  • Muscles of the Ankle and Foot
  • Intrinsic Muscles of the Foot

**Outlines are subject to change, as courses and materials are updated.**

Certification

Upon successful completion of our Medical Coding course, students will be prepared for an entry-level position doing medical coding in a medical office setting and will be prepared to sit for the AHIMA national certification exam to become a Certified Coding Associate (CCA).

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