Active Outline

General Information

Course ID (CB01A and CB01B)
HTEC D072.
Course Title (CB02)
Medical Office Financial Procedures
Course Credit Status
Credit - Degree Applicable
Effective Term
Fall 2024
Course Description
The course focuses on fee determination, billing, diagnostic and procedural coding, commercial and government health insurance programs, and health insurance specialists as a career.
Faculty Requirements
Discipline 1
[Health Care Ancillaries (Medical assisting, hospice worker, home care aide, certified nurse aide, health aide, ward clerk, central service technology, childbirth educator, primary care associate, massage therapy)]
FSA
[FHDA FSA - HEALTH CARE SERVICES]
Course Family
Not Applicable

Course Justification

This course is CSU transferable and part of a CTE program. It was developed based on the California Certifying Board for Medical Assistant's Accreditation Standards required for Health Technology training programs. This course belongs on the Medical Assisting A.S. degree. It provides students in the health technologies field with the essential knowledge of diagnostic and procedural coding in medical facilities, and eligibility benefits guidelines for health insurance companies.

Foothill Equivalency

Does the course have a Foothill equivalent?
No
Foothill Course ID

Course Philosophy

Formerly Statement

Course Development Options

Basic Skill Status (CB08)
Course is not a basic skills course.
Grade Options
  • Letter Grade
  • Pass/No Pass
Repeat Limit
0

Transferability & Gen. Ed. Options

Transferability
Transferable to CSU only

Units and Hours

Summary

Minimum Credit Units
1.5
Maximum Credit Units
1.5

Weekly Student Hours

TypeIn ClassOut of Class
Lecture Hours1.02.0
Laboratory Hours2.00.0

Course Student Hours

Course Duration (Weeks)
12.0
Hours per unit divisor
36.0
Course In-Class (Contact) Hours
Lecture
12.0
Laboratory
24.0
Total
36.0
Course Out-of-Class Hours
Lecture
24.0
Laboratory
0.0
NA
0.0
Total
24.0

Prerequisite(s)

Corequisite(s)

HTEC D101D

Advisory(ies)

HTEC D060A

Limitation(s) on Enrollment

Entrance Skill(s)

General Course Statement(s)

Methods of Instruction

Lecture and visual aids

Discussion of assigned reading

Discussion and problem solving performed in class

Quiz review performed in class

Collaborative learning and small group discussions

Homework and Extended projects

Laboratory quizzes that evaluate the weekly laboratory exercises

Laboratory experience which involves students in formal exercises

Assignments

  1. Reading:
    1. Required readings from the text as preparation for class discussion and application of concepts in written analysis
    2. Assignments from text and supplemental sources in preparation for class discussion
  2. Writing:
    1. Assignments from student mastery manual including key terminology assessment, evaluation of performance, clinical thinking, and crossword puzzles
    2. Complete worksheets that include observations, results and critical analysis
    3. Perform laboratory procedures as outlined in the student mastery manual

Methods of Evaluation

  1. Written Assignments-Critical analysis and discussion of case studies present in lecture and lab or assigned readings
  2. Quizzes-Objective/subjective quizzes that test comprehension of course material on a routine basis and help identify areas that may need extra attention
  3. Objective tests-Written examination designed to demonstrate students understanding of the course material presented in lecture-lab
  4. Lab Activity-Practice and demonstration of techniques in the student laboratory designed to demonstrate critical thinking skills and to problem solve as required in the assignments and experimental investigations
  5. Comprehensive Final Examination-Written test requiring the student to demonstrate their ability to summarize, integrate and critically analyze concepts throughout the course
  6. Comprehensive Practical Examination-Requires students to demonstrate abilities to summarize, integrate, and analyze concepts that have been introduced and studied throughout the course

Essential Student Materials/Essential College Facilities

Essential Student Materials: 
  • None
Essential College Facilities:
  • None

Examples of Primary Texts and References

AuthorTitlePublisherDate/EditionISBN
Green, Michelle A."Understanding Health Insurance: A Guide to Billing and Reimbursement"Cengage Learning2022, 17th Edition
American Medical Association"ICD-10"Optum Publishing Co.2023
American Medical Association"Current Procedural Coding" (CPT)American Medical Association2023

Examples of Supporting Texts and References

None.

Learning Outcomes and Objectives

Course Objectives

  • Demonstrate the Education and training required of a health insurance specialist
  • Describe the responsibilities of a health insurance specialist
  • Discuss the major developments in health insurance
  • Discuss the advantages of implementing the electronic health record
  • Explain the history of managed care in the US
  • Describe the effects of managed care on the physician's practice
  • Describe the processing of an insurance claim
  • Explain the role of credit and collections in processing claims
  • Summarize the legal and regulatory considerations in a practice
  • Describe the Health Insurance Portability and Accountability Act
  • Interpret ICD-10 coding conventions to accurately assign codes
  • Assign CPT codes to procedures and services
  • List situations in which both HCPCS levels I and II codes are assigned
  • Explain the historical development of CMS reimbursement systems
  • Apply special rules for Medicare physician fee schedule payment system
  • Select and code diagnoses and procedures from case studies and sample reports
  • List and define general insurance billing guidelines
  • Explain the characteristics of commercial insurance plans
  • Differentiate among Blue Cross, Blue Shield, Medicare Part A, B, C, and D coverages, Medicaid, MediCal government programs, TRICARE options, programs, and supplemental plans
  • Describe federal and state workers' compensation programs

CSLOs

  • Illustrate diagnostic and procedural coding in the medical facility.

  • Illustrate eligibility, benefits guidelines for health insurance companies.

Outline

  1. Demonstrate the Education and training required of a health insurance specialist
    1. Coursework in general education
    2. Anatomy and Physiology
    3. English composition and oral communications
    4. Human Relations
    5. Computer Applications
  2. Describe the responsibilities of a health insurance specialist
    1. Independent contractor
    2. Coding
    3. Patient interaction
    4. Claims Examiner
    5. Claims Processor
    6. Researcher
  3. Discuss the major developments in health insurance
    1. Self-insured group health plans
    2. HMO's
    3. CPT and ICD-10 codes
    4. RBRVS
    5. HIPAA
    6. CMS
    7. PPACA
  4. Discuss the advantages of implementing the electronic health record
    1. Access to accurate patient treatment data
    2. Allows evidence-based decision support tools
    3. Automates and streamlines providers workflow
    4. Supports collection of data for research and public health issues
  5. Explain the history of managed care in the US
    1. HMO act
    2. PPO plans
    3. Hybrid plans
    4. Triple option plans
    5. Integrated delivery systems
  6. Describe the effects of managed care on the physician's practice
    1. Separate bookkeeping systems for capitated plans
    2. Preauthorizations
    3. Additional paperwork
    4. Up-to-date lists for referrals
  7. Describe the processing of an insurance claim
    1. Preregistration
    2. Patient registration
    3. Photocopy insurance cards
    4. Eligibility status checking
    5. Data entry
  8. Explain the role of credit and collections in processing claims
    1. Electronic funds transfer
    2. Equal Credit Opportunity Act
    3. Fair Credit Billing Act
    4. Delinquent claims cycle
  9. Summarize the legal and regulatory considerations in a practice
    1. State regulations
    2. Business practice acts
    3. Licensure of insurance-related professionals
  10. Describe the Health Insurance Portability and Accountability Act
    1. Improvement in continuity of health insurance coverage
    2. Combat waste, fraud and abuse in the health care delivery
    3. Promote the use of medical savings accounts
    4. Create standards for EHI transactions
    5. Create privacy standards for health information
  11. Interpret ICD-10 coding conventions to accurately assign codes
    1. Understanding the patient encounter
    2. Condition, scope, evidence, and value
    3. Colons, parentheses, and brackets, and exclusions
  12. Assign CPT codes to procedures and services
    1. Locate main terms and sub-terms in CPT index
    2. Surgical coding modifiers
    3. Pathology and radiology coding
    4. Medicine section coding and symbols
  13. List situations in which both HCPCS levels I and II codes are assigned
    1. AMA development of CPT codes
    2. National codes for orthotics and prosthetics
    3. Injection Usage
    4. Enteral and parenteral therapy
  14. Explain the historical development of CMS reimbursement systems
    1. Prospective payment system
    2. Time and frequency of billing such as once a month or cycle
  15. Apply special rules for Medicare physician fee schedule payment system
    1. Outpatient prospective payment system
    2.  Reimbursement in which Medicare payment is made based on predetermined, fixed amount.
  16. Select and code diagnoses and procedures from case studies and sample reports
    1. Applying coding guidelines
    2. Linking diagnoses with procedure/services
    3. Using diagnosis pointers
    4. Patient record documentation justification
  17. List and define general insurance billing guidelines
    1. Inpatient billing
    2. Observation services
    3. Global fees
    4. Combined med./surg. cases
    5. Attachments
  18. Explain the characteristics of commercial insurance plans
    1. Fee-for-service or indemnity insurance
    2. High-risk pools
    3. Managed care
    4. Multiple coverages
  19. Differentiate among Blue Cross, Blue Shield, Medicare Part A, B, C, and D coverages, Medicaid, MediCal government programs, TRICARE options, programs, and supplemental plans
    1. Participating providers
    2. Preferred Provider Networks
    3. Traditional coverage
    4. Managed care plans
    5. Federal employee program
  20. Describe federal and state workers' compensation programs
    1. Physician's services
    2. Advantage plans
    3. Drug coverage
    4. Eligibility

Lab Topics

  1. Evaluation and management of codes
  2. Researching codes
  3. Workers' compensation and managed care
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