Define nomenclature and identify the role of nomenclature in the electronic health record (EHR).
Define classification systems and identify specific classification systems used for coding for each healthcare delivery system.
Discuss the purposes of diagnostic and procedural coding.
Discuss the classification systems used to code diagnoses and procedures, including the International Classification of Diseases, Current Procedural Terminology, Healthcare Common Procedure Coding System, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and Current Data Terminology.
Discuss how EHRs affect coding and billing processes.
Define and describe computer-assisted coding.
Define and discuss important coding and billing terms such as discharge not final billed and present on admission.
Demonstrate coding and billing processes utilizing EHR software.