MDR 102 - Inpatient Clinical Coding & Secondary Records

 
Description
This course includes the historical development of medical nomenclatures and clinical classification systems and their use in healthcare documentation, statistics, research, education and financial reimbursement through the prospective payment system. The International Classification of Diseases (ICD) classification system in the inpatient setting is emphasized. Secondary databases such as patient registries and clinical indices are presented as data sources in the health care setting. This course requires a per credit health career fee; Check the tuition and fee schedule for the current rate.

1. Apply diagnosis and procedure codes using the ICD classification system.
2. Utilize current regulations and established guidelines in code assignments.
3. Validate coding and sequencing accuracy using clinical information found in the health record.
4. Determine accuracy of diagnostic groupings such as Diagnosis-Related Groups (DRG) in the prospective payment system.
5. Use and maintain electronic applications and work processes to support clinical classification and coding.
6. Collect and maintain secondary databases to meet specific organization needs such as clinical indices and patient registries used in medical research.

1. Medical nomenclatures
2. Clinical classification systems
3. Inpatient clinical coding with the international classification of diseases
4. Diagnosis related group assignment
5. Secondary databases

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