Foundations of Medical Coding and Documentation

About Course

Foundations of Medical Coding and Documentation is a beginner-level course that introduces learners to the essential concepts of medical coding and healthcare documentation. This course provides a clear and thorough understanding of the fundamental coding systems, including ICD-10 and CPT, which are widely used across healthcare settings worldwide.

Designed for individuals new to medical coding, the course emphasizes the importance of accurate documentation and classification of diagnoses and procedures to ensure effective communication and proper billing within healthcare organizations. Students will develop the foundational knowledge required to navigate coding manuals, interpret clinical documentation, and understand the role of coding in healthcare administration.

This course lays the groundwork for learners aspiring to advance into specialized coding roles or pursue certification in medical coding and billing. It is ideal for those seeking to start a career in healthcare or enhance their understanding of medical documentation practices.

Understand the basic principles of medical coding and healthcare documentation
Learn the structure and purpose of ICD-10 and CPT coding systems
Recognize common medical terminology used in coding and documentation
Accurately identify diagnoses and procedures from clinical records
Navigate and use coding manuals effectively for basic code assignment
Appreciate the importance of accurate documentation for billing and healthcare communication
Develop foundational skills to support entry-level roles in medical coding and healthcare administration
Prepare for more advanced coding courses or certification programs

Course Content

Introduction to Medical Coding

What is Medical Coding?
Importance of Coding in Healthcare
Role and Responsibilities of a Medical Coder
Types of Medical Codes
Overview of the Revenue Cycle
Settings Where Coding is Used
Eligibility and Skills Required for Coders
Career Opportunities and Job Profiles
Salary Expectations and Growth Scope
Certification Bodies

Medical Terminology

Introduction to Medical Terms
Prefixes and Their Meanings
Root Words by Body System
Suffixes and Their Usage
Common Abbreviations in Healthcare
Medical Symbols and Acronyms
Terminology for Symptoms and Diagnoses
Terms Related to Procedures and Treatments
Drug and Medication Terminology

Human Anatomy & Physiology

Overview of Human Body Systems
Skeletal System – Bones and Terms
Muscular System and Related Terms
Cardiovascular System – Heart and Blood Vessels
Respiratory System: Lungs and Breathing
Digestive System: Organs and Functions
Nervous System: Brain, Nerves, and Conditions
Urinary System: Terms and Disorders
Reproductive System
Common Diseases and Medical Conditions

ICD-10 Coding System

Introduction to ICD-10 and Its Structure
Format and Components of an ICD Code
Guidelines for Selecting Correct Diagnosis Codes
ICD-10 Chapters Overview
Neoplasm, Infectious Diseases & Injuries Coding
Coding Practice — Symptoms vs Diagnoses
Using the ICD-10 Manual Efficiently
Primary vs Secondary Diagnosis Coding
Common ICD Coding Mistakes
ICD-10 Case Study Practice

CPT Coding System

Introduction to CPT Codin
CPT Code Structure and Sections
Evaluation and Management (E/M) Coding
Surgical Procedure Codes
Radiology and Pathology Codes
CPT Modifiers – Purpose and Use
Guidelines for Choosing Correct CPT Codes
Real-World CPT Coding Examples
CPT Code Lookup Practice
Common Errors in CPT Coding

HCPCS Codes

Overview of HCPCS and Medicare Billing
Levels of HCPCS Codes
Durable Medical Equipment (DME) Codes
Ambulance and Drug Billing Codes
Modifiers in HCPCS
When to Use HCPCS vs CPT
Reimbursement and Billing Rules
Real-Life HCPCS Coding Examples
HCPCS Compliance Tips
Case-Based Practice with HCPCS

Ethics and HIPAA

Introduction to HIPAA
Patient Confidentiality and Privacy Rules
Legal Responsibilities of a Coder
Ethical Issues in Coding
Fraud and Abuse in Medical Billing
Penalties for Violations
Informed Consent and Documentation
Importance of Data Security in Healthcare
Code of Conduct for Medical Coders
Real-Life Scenarios: Ethics Case Studies

Coding Guidelines and Documentation

Understanding Medical Documentation
Abstracting Diagnoses and Procedures
Linking Diagnoses with Services
SOAP Notes and Encounter Forms
Physician vs Facility Documentation
Use of Electronic Health Records
Audit and Quality Assurance in Coding
Avoiding Common Documentation Errors
Review and Cross-Check Methods

About Course

What Will You Learn?

Course Content

Introduction to Medical Coding

What is Medical Coding?

Importance of Coding in Healthcare

Role and Responsibilities of a Medical Coder

Types of Medical Codes

Overview of the Revenue Cycle

Settings Where Coding is Used

Eligibility and Skills Required for Coders

Career Opportunities and Job Profiles

Salary Expectations and Growth Scope

Certification Bodies

Medical Terminology

Introduction to Medical Terms

Prefixes and Their Meanings

Root Words by Body System

Suffixes and Their Usage

Common Abbreviations in Healthcare

Medical Symbols and Acronyms

Terminology for Symptoms and Diagnoses

Terms Related to Procedures and Treatments

Drug and Medication Terminology

Human Anatomy & Physiology

Overview of Human Body Systems

Skeletal System – Bones and Terms

Muscular System and Related Terms

Cardiovascular System – Heart and Blood Vessels

Respiratory System: Lungs and Breathing

Digestive System: Organs and Functions

Nervous System: Brain, Nerves, and Conditions

Urinary System: Terms and Disorders

Reproductive System

Common Diseases and Medical Conditions

ICD-10 Coding System

Introduction to ICD-10 and Its Structure

Format and Components of an ICD Code

Guidelines for Selecting Correct Diagnosis Codes

ICD-10 Chapters Overview

Neoplasm, Infectious Diseases & Injuries Coding

Coding Practice — Symptoms vs Diagnoses

Using the ICD-10 Manual Efficiently

Primary vs Secondary Diagnosis Coding

Common ICD Coding Mistakes

ICD-10 Case Study Practice

CPT Coding System

Introduction to CPT Codin

CPT Code Structure and Sections

Evaluation and Management (E/M) Coding

Surgical Procedure Codes

Radiology and Pathology Codes

CPT Modifiers – Purpose and Use

Guidelines for Choosing Correct CPT Codes

Real-World CPT Coding Examples

CPT Code Lookup Practice

Common Errors in CPT Coding

HCPCS Codes

Overview of HCPCS and Medicare Billing

Levels of HCPCS Codes

Durable Medical Equipment (DME) Codes

Ambulance and Drug Billing Codes

Modifiers in HCPCS

When to Use HCPCS vs CPT

Reimbursement and Billing Rules

Real-Life HCPCS Coding Examples

HCPCS Compliance Tips

Case-Based Practice with HCPCS

Ethics and HIPAA

Introduction to HIPAA

Patient Confidentiality and Privacy Rules

Legal Responsibilities of a Coder

Ethical Issues in Coding

Fraud and Abuse in Medical Billing

Penalties for Violations

Informed Consent and Documentation

Importance of Data Security in Healthcare

Code of Conduct for Medical Coders

Real-Life Scenarios: Ethics Case Studies

Coding Guidelines and Documentation