2014 – 2015
Florida Department of Education
Curriculum Framework 

Program Title:	Medical Information Coder/Biller
Career Cluster:	Health Science

CCC	
CIP Number	0351070707	
Program Type	College Credit Certificate (CCC)	
Program Length	34 credit hours	
CTSO	HOSA: Future Health Professionals; Phi Beta Lambda	
SOC Codes (all applicable) 	29-2071 Medical Records and Health Information Technicians
	
Targeted Occupation List	http://www.labormarketinfo.com/wec/TargetOccupationList.htm	
Perkins Technical Skill Attainment Inventory	http://www.fldoe.org/workforce/perkins/perkins_resources.asp 	
Statewide Articulation	http://www.fldoe.org/workforce/dwdframe/artic_frame.asp 	

Purpose

This certificate program is part of the Health Information Technology AS degree program (1351070708).  

A College Credit Certificate consists of a program of instruction of less than sixty (60) credits of college-level courses, which is part of an AS or AAS degree program and prepares students for entry into employment (Rule 6A-14.030, F.A.C.).

This program offers a sequence of courses that provides coherent and rigorous content aligned with challenging academic standards and relevant technical knowledge and skills needed to prepare for further education and careers in the Health Science career cluster; provides technical skill proficiency, and includes competency-based applied learning that contributes to the academic knowledge, higher-order reasoning and problem-solving skills, work attitudes, general employability skills, technical skills, and occupation-specific skills, and knowledge of all aspects of Health Science career cluster. 

The program is designed to prepare students for employment in a variety of health care settings as entry level coder, medical record coder, coding technician, or coding clerks, or medical coder/billers, SOC Code 29-2071 (Medical Records and Health Information Technicians).  Some colleges may choose to divide the Coder/Biller Certificate into two tracks, one for coding and one for billing.

The content includes but is not limited to medical terminology, anatomy and physiology, coding systems, fundamentals of disease process, including pharmacology, healthcare delivery systems, basics of medical records services, ethical and legal responsibilities, safety/security procedures, basic data processing, and employability skills.

Additional Information relevant to this Career and Technical Education (CTE) program is provided at the end of this document.

Standards

After successfully completing this program, the student will be able to perform the following:

01.0	Demonstrate an understanding of the healthcare delivery system and health occupations. 
02.0	Demonstrate the ability to communicate and use interpersonal skills effectively.
03.0	Explore health informatics and information management as a profession. 
04.0	Demonstrate an understanding of health data concepts. 
05.0	Describe the functions of a health record.
06.0	Demonstrate a basic understanding of Health Information Technology. 
07.0	Discuss classification systems, clinical vocabularies and terminologies. 
08.0	Explore ethical issues in Health Informatics and Health Information Technology. 
09.0	Identify the importance of privacy security standards and health record law in healthcare 
10.0	Demonstrate computer knowledge and skills.
11.0	Demonstrate employability skills.
12.0	Describe the anatomy and physiology of the human body.
13.0	Demonstrate proficiency in the application of medical terminology.
14.0	Demonstrate an understanding of the fundamentals of disease process in relationship to the human body, including pharmacology
15.0	Demonstrate proficiency in use of ICD, HCPCS, and CPT coding systems, both manual and automated.

2014 – 2015
Florida Department of Education
Student Performance Standards

Program Title:	Medical Information Coder/Biller
CIP Number:		0351070707
Program Length:	34 credit hours
SOC Code(s):		29-2071

This certificate program is part of the Health Information Technology AS degree program (1351070708).  At the completion of this program, the student will be able to:
	
01.0	Demonstrate an understanding of the healthcare delivery system and health occupations–The student will be able to:	
01.01	Discuss the evolution of health care.	
01.02	Demonstrate an understanding of the infrastructure of healthcare in the United States.	
01.03	Discuss regulatory agencies and organizations within the healthcare delivery system	
01.04	Recognize levels of education, credentialing requirements, employment opportunities, workplace environments and career growth potential.	
02.0	Demonstrate the ability to communicate and use interpersonal skills effectively–The student will be able to:	
02.01	Develop basic speaking and active listening skills.	
02.02	Develop basic observational skills and related documentation strategies in written and oral form.	
02.03	Identify characteristics of successful and unsuccessful communication including barriers. 	
02.04	Respond to verbal and non-verbal cues. 	
02.05	Compose written communication using correct spelling, grammar, formatting and confidentiality. 	
02.06	Use appropriate medical terminology and abbreviations. 	
02.07	Recognize the importance of courtesy and respect for patients and other healthcare workers and maintain good interpersonal relationships. 	
02.08	Recognize the importance of patient/client educations regarding healthcare. 	
02.09	Adapt communication skills to varied levels of understanding and cultural orientation including diverse age, cultural, economic, ethnic and religious groups. 	
02.10	Recognize elements of communication using a sender-receiver model. 	
02.11	Distinguish between and report subjective and objective information. 	
02.12	Report relevant information in order of occurrence. 	
03.0	Explore health informatics and information management as a profession–The student will be able to:	
03.01	Discuss the history of health information management.	
03.02	Discuss the professional opportunities within the health information management profession (eg. diagnostic services, therapeutic services, health informatics, support services or biotechnology research and development). 	
03.03	Demonstrate knowledge of professional associations within HIM.	
04.0	Demonstrate an understanding of health data concepts–The student will be able to:	
04.01	Describe the various uses of health data (primary and secondary).	
04.02	Describe various characteristics of health data quality and standards.	
05.0	Describe the functions of a health record–The student will be able to:	
05.01	Demonstrate an understanding of the various formats of the health record.	
05.02	Explain the various uses of a health record. 	
05.03	Define the Personal Health Record (PHR).	
05.04	Articulate an understanding between the electronic health record-linked web portals and the PHR.	
06.0	Demonstrate a basic understanding of Health Information Technology–The student will be able to:	
06.01	Discuss how healthcare reform legislation can and does affect the HIT field.	
06.02	Interpret information from Electronic Health Records (EHR) and applications in healthcare	
06.03	Demonstrate an understanding of creation, use, and purpose of the electronic health record.	
07.0	Discuss classification systems, clinical vocabularies and terminologies–The student will be able to:	
07.01	Demonstrate knowledge of HIPAA code sets and classification systems as they relate to HIT.	
07.02	Demonstrate knowledge of clinical terminologies as they relate to HIT.	
08.0	Explore ethical issues in Health Informatics and Health Information Technology–The student will be able to:	
08.01	Describe the professional code of ethics consistent with healthcare occupations.	
08.02	Explain the importance of maintaining ethical and legal standards in compiling and using medical records.	
08.03	Recognize ethical issues related to health information technology.	
08.04	Recognize ethical issues related to coding and billing/medical transcription.	
08.05	Demonstrate ethical coding practices as outlined by AHIMA.	
09.0	Identify the importance of privacy security standards and health record law in healthcare–The student will be able to:	
09.01	Identify standards of the Health Insurance Portability and Accountability Act (HIPAA). 	
09.02	Define and explain the composition of the legal patient record.	
09.03	Comply with policies and procedures for privacy, security, and protected health information (PHI) standards.. 	
09.04	Identify standards of the Health Information Technology for Economic and Clinical Health (HITECH). 	
10.0	Demonstrate computer knowledge and skills–The student will be able to:	
10.01	Demonstrate keyboarding skills.	
10.02	Demonstrate the ability to save files and retrieve files from your computer.	
10.03	Demonstrate ability to connect to the Internet.	
10.04	Demonstrate ability to perform research on the internet by identifying reliable websites.	
10.05	Demonstrate ability to send and receive e-mail.	
10.06	Demonstrate ability to send messages with attached files.	
10.07	Demonstrate ability in word processing to create, edit, save, and print a Microsoft Word document.	
10.08	Demonstrate the ability to create and present a Microsoft PowerPoint project.	
11.0	Demonstrate employability skills–The student will be able to:	
11.01	Identify personal traits or attitudes desirable in a member of the healthcare team. 	
11.02	Define basic professional standards of healthcare workers as they apply to hygiene, dress, language, confidentiality and behavior (i.e. courtesy and self-introductions).	
11.03	Identify documents that may be required when applying for a job. 	
11.04	Write an appropriate resume. 	
11.05	Conduct a job search. 	
11.06	Complete a job application form correctly.	
11.07	Demonstrate competence in job interview techniques. 	
11.08	Recognize levels of education, credentialing requirements, employment opportunities, workplace environments and career growth potential. 	
11.09	Identify acceptable work habits. 	
11.10	Recognize appropriate affective/professional behavior. 	
Students completing intended outcomes 12-15 in this module meet the requirements for Medical Coder/Biller or SOC Code 29-2071 (Medical Records and Health Information Technicians)	
12.0	Describe the anatomy and physiology of the human body–The student will be able to:	
12.01	Describe the structure and function of the respiratory system.	
12.02	Describe the structure and function of the cardio-vascular system.	
12.03	Describe the structure and function of the muscular-skeletal system.	
12.04	Describe the structure and function of nervous, skin, and sensory systems.	
12.05	Describe the structure and function of the reproductive system.	
12.06	Describe the structure and function of the urinary system.	
12.07	Describe the structure and function of the digestive system.	
12.08	Describe the structure and function of the endocrine system.	
13.0	Demonstrate proficiency in the application of medical terminology–The student will be able to:	
13.01	Recognize and identify word parts of medical terminology in daily use.	
13.02	Build, spell and pronounce correctly, appropriate terms from word parts learned and be able to give the meaning of the word.	
13.03	Identify word parts and be able to build, spell and understand new words with those parts.	
13.04	Spell and use medical abbreviations.	
13.05	Recognize and identify terminology of hospital and other clinical forms.	
13.06	Demonstrate use of basic terminology common to medical/surgical practices.	
13.07	Apply medical terminology to interpretation of health record documentation and reimbursement of healthcare services.	
13.08	Use medical dictionaries.	
14.0	Demonstrate an understanding of the fundamentals of disease process in relationship to the human body, including pharmacology–The student will be able to:	
14.01	Demonstrate an understanding of the predisposing factors and direct causes of disease as they relate to the human body.	
14.02	Demonstrate an understanding of the general morphology of organisms and their role in the disease process.	
14.03	Demonstrate an understanding of the pathogenesis of diseases of all the body systems.	
14.04	Demonstrate an understanding of pharmacological agents, uses, treatments, and utilizing drug reference sources.	
14.05	Identify and use diagnostic test terminology.	
15.0	Demonstrate proficiency in use of ICD, HCPCS, and CPT coding systems, both manual and automated. –The student will be able to: 	
15.01	 Use and maintain electronic applications and work processes to support classification and coding	
15.02	Apply diagnosis/procedure codes using ICD coding classification systems. 	
15.03	Apply procedure codes using CPT/HCPCS.	
15.04	Ensure accuracy of diagnostic/procedural groupings such as DRG, APC, etc.	
15.05	Adhere to current regulations and established guidelines in code assignment. Research and implement latest coding practices.	
15.06	Validate coding accuracy using clinical information found in the health record.	
15.07	Use and maintain applications and processes to support other clinical classification and nomenclature systems (such as ICD-10-CM, SNOMED etc.)	
15.08	Resolve discrepancies between coded data and supporting documentation through physician query.	
15.09	Apply policies and procedures for the use of clinical data required in reimbursement and prospective payment systems (PPS) in healthcare delivery.	
15.10	Support accurate billing through coding, charge master, claims management, and bill reconciliation processes.	
15.11	Use established guidelines to comply with reimbursement and reporting requirements such as the National Correct Coding initiative.	
15.12	Compile patient data and perform data quality reviews to validate code assignment and compliance with reporting requirements such as outpatient prospective payment system.	

Additional Information

Laboratory Activities

Laboratory activities are an integral part of this program.  These activities include instruction in the use of safety procedures, tools, equipment, materials, and processes related to these occupations.  Equipment and supplies should be provided to enhance hands-on experiences for students. 

Special Notes

This program is part of Health Information Technology or Office Administration - Medical Office Specialization.  The College Credit Certificate guarantees transfer of credit of 34 hours toward the AS degree in Health Information Technology or Office Administration.  Minimum entrance requirements for this program include a high school diploma or GED. 

The cooperative method of instruction or clinical rotation is appropriate for this program.  Whenever these methods are offered, the following is required for each student:  a training plan, signed by the student, teacher, and employer, which includes instructional objectives and a list of on-the-job and in-school learning experiences; and a work station which reflects equipment, skills, and tasks which are relevant to the occupation which the student has chosen as a career goal.  The student may receive compensation for work performed. 

Faculty teaching this program must have a minimum of an AS degree in Health Information Management.

Students should be encouraged to become members and participate in the activities of the professional organizations:  American Health Information Management Association and/or American Academy of Procedural Coders.  

About AHIMA Credentials:
Students who complete the Medical Biller Coder program may take the Certified Coding Associate (CCA) credential exam as the first step in their coding career.  The CCA is an entry-level credential that distinguishes new coders in the job market.  Individuals with a CCA credential: 

•	Exhibit a level of commitment, competency, and professional capability usually absent in a newcomer to the field. 
•	Demonstrate a commitment to the coding profession. 
•	Distinguish themselves from non-credentialed coders and those holding credentials from other organizations less demanding of the higher level of expertise required to earn AHIMA certification. 

The CCA should be viewed as the starting point for an individual entering a career as a coder. The AHIMA CCS and CCS-P exams demonstrate mastery level skills in coding.  Most individuals challenge the CCS or CCS-P exams after two or more years of work experience in coding. 

American Health Information Management Association
919 North Michigan Ave., Suite 2150
Chicago, IL. 60611-5519
(312) 233-1100

The American Academy of Professional Coders (AAPC) sponsors a certification exam for coders with expertise in physician-based settings which leads to the title of Certified Professional Coder (CPC) or Certified Professional Coder Hospital (CPC-H).

American Academy of Professional Coders
309 West 700 South
Salt Lake City, UT 84101
800-626-2633

The National Healthcare Association also offers a national certification examination for a Certified Billing and Coding Specialist (CBCS).

National Healthcareer Association
7500 West 160th Street
Stilwell, Kansas  66085
800-499-9092 
www.nhanow.com

Outcomes 01-11 are referred to as the Health Information Technology core and do not have to be completed if the students has previously completed the core in another program at any level. The Core should be taken first or concurrently with the first course in the program. 

Career and Technical Student Organization (CTSO)

HOSA: Future Health Professionals is the appropriate career and technical student organization for providing leadership training and reinforcing specific career and technical skills.  Career and Technical Student Organizations provide activities for students as an integral part of the instruction offered.  The activities of such organizations are defined as part of the curriculum in accordance with Rule 6A-6.065, F.A.C.

Accommodations

Federal and state legislation requires the provision of accommodations for students with disabilities as identified on the secondary student’s Individual Educational Plan (IEP) or 504 plan or postsecondary student’s accommodations’ plan to meet individual needs and ensure equal access.  Postsecondary students with disabilities must self-identify, present documentation, request accommodations if needed, and develop a plan with their counselor and/or instructors.  Accommodations received in postsecondary education may differ from those received in secondary education.  Accommodations change the way the student is instructed.  Students with disabilities may need accommodations in such areas as instructional methods and materials, assignments and assessments, time demands and schedules, learning environment, assistive technology and special communication systems.  Documentation of the accommodations requested and provided should be maintained in a confidential file.

Articulation

For details on articulation agreements which correlate to programs and industry certifications refer to http://www.fldoe.org/workforce/dwdframe/artic_frame.asp.