MEDICAL CODING AND CLAIMS PROCESSING NC III – TESDA COURSE MODULE

TESDA TRAINING REGULATIONS FOR MEDICAL CODING AND CLAIMS PROCESSING NC III COURSE

The TESDA Course in MEDICAL CODING AND CLAIMS PROCESSING NC III consists of competencies that a person must achieve to demonstrate a proficiency in assigning internationally prescribed diagnostic and procedural codes associated with billing and reimbursement in compliance with clinical documentation requirements.

This Qualification is packaged from the competency map of the Information and Communication Technology Industry (Service sector)

A student who has achieved this TESDA Course in MEDICAL CODING AND CLAIMS PROCESSING NC III is competent to be:

• Medical/Clinical Coding Specialist
• Medical/Clinical Claims Specialist

TRAINEE ENTRY REQUIREMENTS

Trainees or students wishing to gain entry into this course should possess the following requirements:

• Graduate of 12-years Basic education;
• Can communicate in English, both oral and written;
• Have pass the trainability/aptitude test of the institution*

Note: * Optional

This list does not include specific institutional requirements such as educational attainment, appropriate work experience, and others that may be required of the trainees by the school or training center delivering the TVET program.

MEDICAL CODING AND CLAIMS PROCESSING NC III COURSE MODULE

Course Title: MEDICAL CODING AND CLAIMS PROCESSING
Level: NC III
Nominal Training Duration :

(Basic Competency) 32 hours
(Common Competency) 18 hours
(Core Competency) 160 hours

TOTAL DURATION: 210 Hours

This course is designed to develop knowledge, desirable attitudes, and skills in assigning medical codes to medical conditions and procedures and services from medical reports made by physicians and other health care professional for reporting and billing/claims purposes. It covers specialized competencies such as assigning medical codes, processing and managing of medical claims.

COMPETENCIES REQUIRED IN MEDICAL CODING AND CLAIMS PROCESSING NC III

This units of competency comprising this qualification include Basic, Common and Core Competencies.

To obtain this TESDA Course in MEDICAL CODING AND CLAIMS PROCESSING NC III, all units prescribed below for this qualification must be achieved.

These units of competency comprising this qualification include the following:

UNIT CODE	CORE COMPETENCIES (160 hours)
ICT325301	Assign medical codes
ICT325302	Process medical claims/billing
ICT325303	Manage medical claims
UNIT CODE	COMMON COMPETENCIES (18 hours)
ICT315202	Apply quality standards
ICT311203	Perform computer operations
UNIT CODE	BASIC COMPETENCIES (32 hours)
500311109	Lead Workplace Communication
500311110	Lead Small Teams
500311111	Develop and Practice Negotiation skills
500311112	Solve Problems Related to Work Activities
500311113	Use Mathematical Concepts and Techniques
500311114	Use Relevant Technologies

These guidelines are set to provide the Technical Vocational Education and Training (TVET) providers with information and other important requirements to consider when designing training programs for MEDICAL CODING AND CLAIMS PROCESSING NC III.

CORE COMPETENCIES

UNIT TITLE : ASSIGN MEDICAL CODES
UNIT CODE : ICT325301

This unit covers the skills, knowledge and attitude necessary to assign codes for medical diagnoses, procedures, services, supplies, equipment, and other services.

1. Prepare requirements for medical coding
   • Patient’s medical records/charts are retrieved from client’s system
   • Coding tools/system to be used for medical coding are prepared based on client’s specification/coding guidelines
2. Evaluate medical reports
   • Medical information necessary for coding are analyzed for completeness based on client’s specification/coding guidelines
   • Medical Report is reviewed to determine the appropriate diagnoses, procedures equipment & supplies based on client’s specification/coding guidelines.
   • When necessary, specific requirements of insurance/ payor are considered
   • Lacking data based on the initial screening result are requested from the client
3. Assign codes
   • Medical terms to be reported are searched or located in the Alphabetic index of the appropriate coding reference/s
   • Code numbers are verified using the tabular list of the coding manual
   • Verified medical code or codes are assigned to the highest level of details in line with coding standards and guidelines
   • Unclear/Questionable cases are clarified with appropriate resource person/s in line with enterprise procedures
   • Coding information/requirements are verified for completeness of data based on the required fields prior to submission

UNIT TITLE : PROCESS MEDICAL CLAIMS/BILLING
UNIT CODE : ICT325302

This unit covers the skills, knowledge and attitude necessary to process medical claims/billing. It covers preparation of requirements for screening and processing of claims/billing.

1. Prepare requirements for claims processing
   • Data are gathered from patient’s record as provided by the client.
   • Patient’s medical record are created or updated based on claims processing requirements
   • Medical provider’s demographics are checked and updated based on claims processing requirements
2. Screen claims
   • Claims are checked for authorization, eligibility based on provider and/or subscriber contract with the payer
   • Completeness of claims documentation are checked in accordance with payer requirements
   • Lacking data based on the initial screening result are requested from medical provider
3. Process claims/billing
   • Encode patient, provider and/or billing information
   • Determine reimbursable procedures and/or services based on existing insurance contract or provider contract or any existing reimbursement guidelines
   • Billing information is verified for completeness of data based on the required fields.
   • Determine billing address and facility based on insurance contract

UNIT TITLE : MANAGE MEDICAL CLAIMS
UNIT CODE : ICT325303

This unit covers the skills, knowledge and attitude necessary to manage medical claims. It covers managing account receivable, denials/ rejections and underpaid medical claims.

1. Manage account receivable
   • Processed and submitted claims are tracked and monitored based on enterprise or client requirements
   • Pending claims are followed-up from payer and/or patient in accordance with enterprise policy
   • Supporting documents are Identified and requested from the medical provider based on payer requirements (when necessary)
   • Posting of payments are performed in accordance with enterprise/client’s policy
2. Manage denied/rejected claims
   • Denied/ Rejected claims are reviewed based on the explanation of benefits from the insurance company.
   • Reasons for denial/rejections are verified with payer’s adjusters in line with enterprise policy.
   • Necessary adjustments are made based on the explanation of benefits from the insurance company.
   • Supporting documents are Identified and requested from the medical provider based on the payer requirements.
   • Adjusted claims are resubmitted in compliance with payer’s requirements
3. Manage underpaid claims
   • Underpaid claims are reviewed based on the explanation of benefits from the insurance company.
   • Reasons for underpayment are verified with payer’s adjusters in line with enterprise policy.
   • Supporting documents are prepared based on payer requirements.
   • Underpaid claims are resubmitted together with appeal request in line with enterprise/client’s policy.

COMMON COMPETENCIES

UNIT TITLE : APPLY QUALITY STANDARDS
UNIT CODE : ELC315202

This unit covers the knowledge, skills, (and) attitudes and values needed to apply quality standards in the workplace.

The unit also includes the application of relevant safety procedures and regulations, organization procedures and customer requirements

1. Assess quality of received materials or components
   • Work instructions are obtained and work is carried out in accordance with standard operating procedures
   • Received materials or component parts are checked against workplace standards and specifications
   • Faulty material or components related to work are identified and isolated
   • Faults and any identified causes are recorded and/or reported to the supervisor concerned in accordance with workplace procedures
   • Faulty materials or components are replaced in accordance with workplace procedures
2. Assess own work
   • Documentation relative to quality within the company is identified and used
   • Completed work is checked against workplace standards relevant to the task undertaken
   • Faulty pieces are identified and isolated
   • Information on the quality and other indicators of production performance is recorded in accordance with workplace procedures
   • Deviations from specified quality standards, causes are documented and reported in accordance with the workplace’ standards operating procedures
3. Engage in quality improvement
   • Process improvement procedures are participated in relation to workplace assignment
   • Work is carried out in accordance with process improvement procedures
   • Performance of operation or quality of product or service to ensure customer satisfaction is monitored

UNIT TITLE : PERFORM COMPUTER OPERATIONS
UNIT CODE : ELC311203

This unit covers the knowledge, skills, (and) attitudes and values needed to perform computer operations which include inputting, accessing, producing and transferring data using the appropriate hardware and software

1. Plan and prepare for task to be undertaken
   • Requirements of task are determined according to job specifications
   • Appropriate hardware and software are selected according to task assigned and required outcome
   • Task is planned to ensure OH & S guidelines and procedures are followed
2. Input data into computer
   • Data are entered into the computer using appropriate program/application in accordance with company procedures
   • Accuracy of information is checked and information is saved in accordance with standard operating procedures
   • Inputted data are stored in storage media according to requirements
   • Work is performed within ergonomic guidelines
3. Access information using computer
   • Correct program/application is selected based on job requirements
   • Program/application containing the information required is accessed according to company procedures
   • Desktop icons are correctly selected, opened and closed for navigation purposes
   • Keyboard techniques are carried out in line with OH & S requirements for safe use of keyboards
4. Produce/output data using computer system
   • Entered data are processed using appropriate software commands
   • Data printed out as required using computer hardware/peripheral devices in accordance with standard operating procedures
   • Files, data are transferred between compatible systems using computer software, hardware/ peripheral devices in accordance with standard operating procedures
5. Maintain computer equipment and systems
   • Systems for cleaning, minor maintenance and replacement of consumables are implemented
   • Procedures for ensuring security of data, including regular back-ups and virus checks are implemented in accordance with standard operating procedures
   • Basic file maintenance procedures are implemented in line with the standard operating procedures

BASIC COMPETENCIES

The BASIC COMPETENCIES refer to non-technical skills (knowledge, skills and attitudes) that everybody will need in order to perform satisfactorily at work and in society and are considered portable and transferable irrespective of jobs and industrial settings.

UNIT OF COMPETENCY : LEAD WORKPLACE COMMUNICATION
UNIT CODE : 500311109

This unit covers the knowledge, skills and attitudes required to lead in the dissemination and discussion of ideas, information and issues in the workplace.

1. Communicate information about workplace processes
   • Appropriate communication method is selected
   • Multiple operations involving several topics areas are communicated accordingly
   • Questions are used to gain extra information
   • Correct sources of information are identified
   • Information is selected and organized correctly
   • Verbal and written reporting is undertaken when required
   • Communication skills are maintained in all situations
2. Lead workplace discussions
   • Response to workplace issues are sought
   • Response to workplace issues are provided immediately
   • Constructive contributions are made to workplace discussions on such issues as production, quality and safety
   • Goals/objectives and action plan undertaken in the workplace are communicated
3. Identify and communicate issues arising in the workplace
   • Issues and problems are identified as they arise
   • Information regarding problems and issues are organized coherently to ensure clear and effective communication
   • Dialogue is initiated with appropriate personnel
   • Communication problems and issues are raised as they arise

UNIT OF COMPETENCY : LEAD SMALL TEAMS
UNIT CODE : 500311110

This unit covers the knowledge, skills and attitudes to lead small teams including setting and maintaining team and individual performance standards.

1. Provide team leadership
   • Work requirements are identified and presented to team members
   • Reasons for instructions and requirements are communicated to team members
   • Team members’ queries and concerns are recognized, discussed and dealt with
2. Assign responsibilities
   • Duties, and responsibilities are allocated having regard to the skills, knowledge and aptitude required to properly undertake the assigned task and according to company policy
   • Duties are allocated having regard to individual preference, domestic and personal considerations, whenever possible
3. Set performance expectations for team members
   • Performance expectations are established based on client needs and according to assignment requirements
   • Performance expectations are based on individual team members duties and area of responsibility
   • Performance expectations are discussed and disseminated to individual team members
4. Supervised team performance
   • Monitoring of performance takes place against defined performance criteria and/or assignment instructions and corrective action taken if required
   • Team members are provided with feedback, positive support and advice on strategies to overcome any deficiencies
   • Performance issues which cannot be rectified or addressed within the team are referenced to appropriate personnel according to employer policy
   • Team members are kept informed of any changes in the priority allocated to assignments or tasks which might impact on client/customer needs and satisfaction
   • Team operations are monitored to ensure that employer/client needs and requirements are met
   • Follow-up communication is provided on all issues affecting the team
   • All relevant documentation is completed in accordance with company procedures

UNIT OF COMPETENCY : DEVELOP AND PRACTICE NEGOTIATION SKILLS
UNIT CODE : 500311111

This unit covers the skills, knowledge and attitudes required to collect information in order to negotiate to a desired outcome and participate in the negotiation.

1. Plan negotiations
   • Information on preparing for negotiation is identified and included in the plan
   • Information on creating non verbal environments for positive negotiating is identified and included in the plan
   • Information on active listening is identified and included in the plan
   • Information on different questioning techniques is identified and included in the plan
   • Information is checked to ensure it is correct and up-to- date
2. Participate in negotiations
   • Criteria for successful outcome are agreed upon by all parties
   • Desired outcome of all parties are considered
   • Appropriate language is used throughout the negotiation
   • A variety of questioning techniques are used
   • The issues and processes are documented and agreed upon by all parties
   • Possible solutions are discussed and their viability assessed
   • Areas for agreement are confirmed and recorded
   • Follow-up action is agreed upon by all parties

UNIT OF COMPETENCY : SOLVE PROBLEMS RELATED TO WORK ACTIVITIES
UNIT CODE : 500311112

This unit of covers the knowledge, skills and attitudes required to solve problems in the workplace including the application of problem solving techniques and to determine and resolve the root cause of problems.

1. Identify the problem
   • Variances are identified from normal operating parameters; and product quality
   • Extent, cause and nature are of the problem are defined through observation, investigation and analytical techniques
   • Problems are clearly stated and specified
2. Determine fundamental causes of the problem
   • Possible causes are identified based on experience and the use of problem solving tools / analytical techniques.
   • Possible cause statements are developed based on findings
   • Fundamental causes are identified per results of investigation conducted
3. Determine corrective action
   • All possible options are considered for resolution of the problem
   • Strengths and weaknesses of possible options are considered
   • Corrective actions are determined to resolve the problem and possible future causes
   • Action plans are developed identifying measurable objectives, resource needs and timelines in accordance with safety and operating procedures
4. Provide recommendation/s to manager
   • Report on recommendations are prepared
   • Recommendations are presented to appropriate personnel.
   • Recommendations are followed-up, if required

UNIT OF COMPETENCY : USE MATHEMATICAL CONCEPTS AND TECHNIQUES
UNIT CODE : 500311113

This unit covers the knowledge, skills and attitudes required in the application of mathematical concepts and techniques.

1. Identify mathematical tools and techniques to solve problem
   • Problem areas are identified based on given condition
   • Mathematical techniques are selected based on the given problem
2. Apply mathematical procedure/solution
   • Mathematical techniques are applied based on the problem identified
   • Mathematical computations are performed to the level of accuracy required for the problem
   • Results of mathematical computation is determined and verified based on job requirements
3. Analyze results
   • Result of application is reviewed based on expected and required specifications and outcome
   • Appropriate action is applied in case of error

UNIT OF COMPETENCY : USE RELEVANT TECHNOLOGIES
UNIT CODE : 500311114

This unit of competency covers the knowledge, skills, and attitude required in selecting, sourcing and applying appropriate and affordable technologies in the workplace.

1. Study/select appropriate technology
   • Usage of different technologies is determined based on job requirements
   • Appropriate technology is selected as per work specification
2. Apply relevant technology
   • Relevant technology is effectively used in carrying out function
   • Applicable software and hardware are used as per task requirement
   • Management concepts are observed and practiced as per established industry practices
3. Maintain/enhance relevant technology
   • Maintenance of technology is applied in accordance with the industry standard operating procedure, manufacturer’s operating guidelines and occupational health and safety procedure to ensure its operative ability
   • Updating of technology is maintained through continuing education or training in accordance with job requirement
   • Technology failure/ defect is immediately reported to the concern/responsible person or section for appropriate action

DEFINITION OF TERMS

GENERAL

• Certification – is the process of verifying and validating the competencies of a person through assessment
• Certificate of Competency (COC) – is a certification issued to individuals who pass the assessment for a single unit or cluster of units of competency
• Common Competencies – are the skills and knowledge needed by all people working in a particular industry
• Competency – is the possession and application of knowledge, skills and attitudes to perform work activities to the standard expected in the workplace
• Competency Assessment – is the process of collecting evidence and making judgments on whether competency has been achieved
• Competency Standard (CS) – is the industry-determined specification of competencies required for effective work performance
• Context of Assessment – refers to the place where assessment is to be conducted or carried out
• Core Competencies – are the specific skills and knowledge needed in a particular area of work – industry sector/occupation/job role
• Critical aspects of competency – refers to the evidence that is essential for successful performance of the unit of competency
• Elective Competencies – are the additional skills and knowledge required by the individual or enterprise for work
• Elements – are the building blocks of a unit of competency. They describe in outcome terms the functions that a person performs in the workplace.
• Evidence Guide – is a component of the unit of competency that defines or identifies the evidences required to determine the competence of the individual. It provides information on critical aspects of competency, underpinning knowledge, underpinning skills, resource implications, assessment method and context of assessment
• Level – refers to the category of skills and knowledge required to do a job
• Method of Assessment – refers to the ways of collecting evidence and when,
  evidence should be collected
• National Certificate (NC) – is a certification issued to individuals who achieve all the required units of competency for a national qualification defined under the Training Regulations. NCs are aligned to specific levels within the PTQF
• Performance Criteria – are evaluative statements that specify what is to be assessed and the required level of performance
• Qualification – is a cluster of units of competencies that meets job roles and is significant in the workplace. It is also a certification awarded to a person on successful completion of a course in recognition of having demonstrated competencies in an industry sector
• Range of Variables – describes the circumstances or context in which the work is to be performed
• Recognition of Prior Learning (RPL) – is the acknowledgement of an individual’s skills, knowledge and attitudes gained from life and work experiences outside registered training programs
• Resource Implications – refers to the resources needed for the successful performance of the work activity described in the unit of competency. It includes work environment and conditions, materials, tools and equipment
• Basic Competencies – are the skills and knowledge that everyone needs for work
• Training Regulations (TR) – refers to the document promulgated and issued by TESDA consisting of competency standards, national qualifications and training guidelines for specific sectors/occupations. The TR serves as basis for establishment of qualification and certification under the PTQF. It also serves as guide for development of competency-based curricula and instructional materials including registration of TVET programs offered by TVET providers
• Underpinning Knowledge – refers to the competency that involves in applying knowledge to perform work activities. It includes specific knowledge that is essential to the performance of the competency
• Underpinning Skills – refers to the list of the skills needed to achieve the elements and performance criteria in the unit of competency. It includes generic and industry specific skills
• Unit of Competency – is a component of the competency standards stating a specific key function or role in a particular job or occupation; it is the smallest component of achievement that can be assessed and certified under the PTQF

SECTOR SPECIFIC

• Anatomy – the branch of morphology concerned with the structure of animals or plants.
• Browser – a software package that provides the user interface for accessing Internet, intranet and extranet Web sites.
• Claims processing – is the fulfillment by an insurer of its obligation to receive, investigate and act on a claim filed by an insured. It involves multiple administrative and customer service layers that includes review, investigation, adjustment (if necessary), remittance or denial of the claim.
• Computer – a device that has the ability to accept data; internally store and execute a program of instructions; perform mathematical, logical, and manipulative operations on data; and report the results.
• Computer Terminal – any input/output device connected by telecommunications links to a computer.
• Data – objective measurements of the attributes (characteristics) of entities such as people, places, things, and events.
• Documentation – a collection of documents or information.
• Edit – to modify the form or format of data
• Encryption – to scramble data or convert it, prior to transmission, to a secret code that masks the meaning of he data to unauthorized recipients.
• End user – anyone who uses an information system or the information it produces.
• Ergonomics – the science and technology emphasizing the safety, comfort, and ease of use of human-operated machines. The goal of ergonomics is to produce systems that are user-friendly: safe, comfortable and easy to use.
• Information – data placed in a meaningful and useful context for an end user.
• Information and Communication Technology (ICT) – refers to technologies associated with the transmission and exchange of data in the form of sound, text, visual images, signals or any combination of those forms through the use of digital technology. It encompasses such services as telecommunications, posts, multimedia, electronic commerce, broadcasting, and information technology.
• Keyboarding – using the keyboard of a microcomputer or terminal.
• Knowledge workers – people whose primary work activities include creating, using, and distributing information.
• Local Area Network (LAN) – a communications network that typically connects computers, terminals, and other computerized devices within a limited physical area such as an office, building, manufacturing plant and other work sites.
• Medical billing – is the process of submitting and following up on claims with health insurance companies in order to receive payment for services rendered by a healthcare provider. It is an interaction between a health care provider and the insurance company (payer).The same process is used for most insurance companies, whether they are private companies or government sponsored programs.
• Medical claims processor – manages and processes insurance claims. When healthcare providers treat patients, they file a medical claim to receive payment from the patient’s insurance company. The medical claims processor then reviews and assesses the claim, remitting payment to the doctor if a claim is covered by the patient’s insurance policy. Due to the nature of the work, it is vital that the processor be knowledgeable about the health insurance industry.
• Outsourcing – turning over all or part of an organization’s information systems operation to outside contractors, known as systems integrators or facilities management companies.
• Physiology – the branch of biology concerned with the functions of living things.
• Protocol – a set of rules and procedures for the control of communication in a communications network.
• Quality Assurance – methods for ensuring that information systems are free from errors and fraud and provide information products of high quality.
• Software – computer programs and procedures concerned with the operation of an information system.
• Standards – measures of performance developed to evaluate the progress of a system toward its objectives
• System – an assembly of methods, procedures, or techniques unified by regulated interaction to form an organized whole
• User- friendly – a characteristic of human-operated equipment and systems that makes