Clinical coding is critical for public health reporting. It helps in the assessment of the quality of care, leading to improved health services planning, education, research, and performance monitoring.
The widely used code set for diagnoses is the International Classification of Diseases (ICD), of which the latest implemented version is the 10th edition (ICD-10). The code sets currently used in the Kingdom of Saudi Arabia are ICD-10-AM (Australian modification) for diagnosis reporting in all healthcare settings and the Australian Classification of Health Interventions (ACHI) for inpatient procedure reporting.
A comprehensive team of experts from ACCUMED Practice Management and the American Health Information Management Association (AHIMA), came together to develop the Kingdom of Saudi Arabia Billing System (KBS) in response to the requirements and compliance by the regulator that led to the development of this program.
This Outpatient Coder Certificate Program focuses on training healthcare professionals for coding in the ambulatory setting using ICD-10-AM and the Council of Cooperative Health Insurance - Billing System(CCHI-BS).
The Outpatient Coder Certificate Program consists of total 12 modules beginning with an introduction to each of the classifications of the Council of Cooperative Health Insurance - Billing System (CCHI-BS). then moving on to specialty-specific coding, and culminating with a practicum involving application of codes to ambulatory cases.
Those who successfully complete all 12 modules in addition to fulfilling the pre-requisite requirements of other three courses; are eligible to take the Outpatient Coder Certificate exam, administered by AHIMA.
By the end of this certificate program, you will be able to:
Identify the structure and organization of the International Statistical Classification of Diseases and Related Health Problems – Tenth Revision – Australian Modification (ICD-10-AM), Council of Cooperative Health Insurance - Billing System (CCHI-BS)
Apply the conventions and instructions found in ICD-10-AM, CCHI-BS
Determine diagnosis and procedure codes for ambulatory cases
Program Learning Outcomes
Top 5 learning outcomes you will achieve by attending this program
Successfully demonstrate the important role of the coding profession within the healthcare delivery system
Evaluate the compliance of health record content within the health organization
Determine diagnosis and procedure codes according to official coding guidelines
Adhere to workplace policies, procedures, and professional requirements
Ensure compliance with KSA regulatory requirements
Clinical documentation is at the core of every patient encounter. This documentation must be clear, consistent, complete, reliable, timely, and legible to accurately reflect the patient’s disease burden and scope of services provided.
The purpose of Clinical documentation integrity (CDI) programs facilitates the accurate representation of a patient’s clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, disease tracking and trending, and medical research.
The convergence of clinical care, documentation, and coding processes is critical to appropriate reimbursement, accurate quality scores, and informed decision-making to support high-quality patient care. Hence; CDI has a direct impact on patient care by providing information to all members of the care team.
CDI Program Objectives
The goal of clinical documentation improvement is accuracy, clinical soundness and final coding of a record after the discharge and helps to:
Improve quality of care by correctly capturing the patient SOI, ROM and ALOS, so that the hospitals can report the appropriate level of care
Standardize medical data for research and track analysis (W.H.O)
Augment the case mix index of the hospitals
Minimize claims rejections by the insurance
Apply suitable hospitals reimbursements for the level of care they provide
Maximize the DRG assignment and optimize payments for the services rendered to the patient
By attending the CDI courses; you should be able to:
Understand the importance of Clinical Documentation improvement and the Diagnosis Specificity impact on the patient quality care
Manage the coding and diagnostic elements that should be identified to support high quality clinical documentation and coding
Differentiate between clinical vs diagnostic terms
Identify common ICD-10-AM Documentation Requirements for the procedures
Pin-point the common severity drivers for effective treatment and results