Main description:

This book was written to provide trainees with the knowledge and skills necessary to work in a variety of medical billing and coding positions in the medical field. Easy to read and comprehend, it is designed for professionals who have not previously worked in the medical field as well as professionals who have worked in the field but have only been exposed to certain aspects of the billing process. In order to adapt to the growing number of facilities that are becoming more automated, this book not only reviews non-automated procedures but it also gives in-depth content on automated procedures. A few exciting features to this book are: Case Studies with Critical Thinking Questions; a key terms list appears at the beginning of each chapter; Professional Tips appear throughout the text and provide additional information related to billing and coding processes; and any material within the text that is related to HIPAA is flagged with an icon so that students can identify the "need to know" law.

Contents:

Preface Section I - A Career in Healthcare CHAPTER 1: INTRODUCTION TO PROFESSIONAL BILLING AND CODING CAREERS Employment Demand Facilities Physician Practice Hospital Centralized Billing Office Job Descriptions Medical Office Assistant Medical Biller Medical Coder Registered Health Information Technicians (RHIT) Payment Poster Medical Collector Refund Specialist Insurance Verification Representative Admitting Clerk or Front Desk Representative Patient Information Clerk Professional Memberships Certification Medical Office Assistant Certification Medical Billing Certifications Medical Coding Certifications Medical Records Certification Resources Section II: Relationship between the Patient, Provider and Carrier CHAPTER 2: MANAGED CARE TERMINOLOGY The History of Healthcare in America Medical Reform Definition of Managed Health Care Managing and Controlling Cost Discounted Fees Patient Care Delivered Is Medically Necessary Care Rendered By Appropriate Provider Appropriate Medical Care in Least Restrictive Setting Withholding Providers, Funds Insurance Plans Commercial Health Insurance Types of Managed Care Organizations Health Maintenance Organizations (HMO) Preferred Provider Organization (PPO) Point Of Service Options (POS) Criticism of MCOs Alternative Health Care Plans Exclusive Provider Organization (EPO) Independent Physician Association (IPA) Physician-Hospital Organization (PHO) Self-insured Employers Types of Insurance Coverage Hospital Hospital Indemnity Insurance Medical Surgical Outpatient Major Medical Special Risk Catastrophic Health Insurance Short-Term Health Insurance Cobra Insurance Full-Service Health Insurance Long-Term Care Supplemental Insurance The Provider,s View of Managed Care Restrictions Opportunities Patient Care Facility Operations Collection of Funds Assignment of Benefits CHAPTER 3: UNDERSTANDING MANAGED CARE: MEDICAL CONTRACTS AND ETHICS Purpose of a Contract A Legal Agreement Compensation and Billing Guidelines Covered Medical Expenses Payment Ethics in Managed Care Changes in Health Care Delivery Ethics of the Medical Office Specialist Contract Definitions Compensation for Services Patient Bill of Rights Section III: Medical Coding CHAPTER 4: ICD-9 MEDICAL CODING Definitions of Diagnosis Coding History of Diagnosis Coding Purpose of ICD-9-CM Addenda The Future of Diagnostic Coding: ICD-10-CM The Three Volumes of the ICD-9-CM Volume I: Tabular/Numerical List of Diseases Volume II: Alphabetic Index of Diseases Volume III: Tabular and Alphabetic Index of Procedures Proper Use of the ICD-9-CM ICD-9-CM Conventions The Alphabetic Index- Volume 2 Supplementary Terms Introduction to Volume I The Tabular List: Volume I How to Code Key Coding Guidelines Primary Diagnosis First, Followed by Current Coexisting Conditions Code to Highest Level of Certainty Code to the Highest Level of Specificity Surgical Coding Coding Late Effects Acute and Chronic Conditions Combination Code - Multiple Coding V Codes E Codes Supplemental Classification of External Causes of Injury and Poisoning Neoplasm Table The Fifth-digit Behavior Codes Coronary Artery Disease Ischemic Heart Disease Hypertension Table Poisoning and Adverse Effects of Drugs Burns Diabetes Injuries, Complications and Accidents Fractures Other Scenarios Nine Steps for Accurate ICD-9-CM Coding CHAPTER 5: INTRODUCTION TO CPT AND PLACE OF SERVICE CODING CPT CPT Categories Category I Category II Category III CPT Nomenclature Symbols Guidelines Modifiers List of Modifiers for Evaluation and Management Coding Coding to the Place of Service Office vs. Hospital Services Emergency Department Services Preventive Medicine Service Type of Patient New Patient Established Patient Referral Consultation Level of E/M Service Extent of Patient,s History Extent of Examination Complexity of Medical Decision Making Additional Components Assigning the Code CHAPTER 6: CODING PROCEDURES AND SERVICES Organization of the CPT Index Instructions for Using the CPT Format of the Terminology Format Cross-references Section Guidelines Modifiers Coding Steps Coding for Anesthesia Surgical Coding Add-On Codes (+) Separate Procedure Surgical Package or Global Surgery Concept Supplies and Services Post-op Follow up 99024 Radiology Codes Pathology and Laboratory Codes Medicine CHAPTER 7: HCPCS AND CODING COMPLIANCE History of HCPCS HCPCS Level of Codes Level I - CPT Level II - HCPCS National Codes Level III - Local Codes HCPCS Modifiers The Use of the GA Modifier Index Coding Linkage and Coding Compliance Code Linkage Billing CPT-4 Codes Federal Law Physician Self-Referral Government Investigations and Advice Errors Relating to Code Linkage and Medical Necessity Errors Relating to the Coding Process Errors Relating to the Billing Process National Correct Coding Initiative (NCCI) Fraudulent Actions and Compliance Errors Compliance How to be Compliant Benefits of a Voluntary Compliance Program Ethics for the Medical Coder CHAPTER 8: AUDITING Auditing External Audit Internal Audit Purpose of an Audit Private Payer Regulations Medical Necessity for E/M Services Audit Tool Key Elements of Service History Examination Medical Decision Making Tips for Preventing Coding Errors with Specific E/M Codes Section IV: Medical Claims CHAPTER 9: PHYSICIAN MEDICAL BILLING Patient Information Superbills Types of Insurance Claims Optical Character Recognition CMS - 1500 Form Physicians, Identification Numbers Common Reasons why CMS-1500 Claim Forms are Delayed or Rejected HIPAA Compliance Alert Filing Secondary Claims Determining Primary Coverage CHAPTER 10: HOSPITAL MEDICAL BILLING Inpatient Billing Process Charge Description Master Types of Payers Coding and Reimbursement Methods Diagnosis Related Group System (DRG) Cost Outliers ICD-9CM Procedural Coding Hospital Billing Claim Form (UB-04) Instructions for Completing UB-04 Codes for UB-04 Sex Codes Admission Codes Discharge Codes Condition Codes Occurrence Code Examples (Form Locater 31-34) Value Codes Revenue Codes Patient Relationship Section V: Government Medical Billing CHAPTER 11: MEDICARE MEDICAL BILLING Medicare History Medicare Administration Medicare Intermediary- Part A Medicare Carrier- Part B Claim Processing: Medicare Part A Provider- Intermediary Inpatient Hospital Care Skilled Nursing Facility Home Health Care Hospice Care Inpatient Benefit Days Basic Days Co-Insurance Days Lifetime Reserve Days (LTR) Skilled Nursing Facility Hospice Care Claims Processing: Medicare Part B- Carrier Medicare Part C Medicare Part D Services Not Covered by Medicare Part A and Part B Requirements for Medical Necessity Fee-for-Service: The Original Medicare Plan Medicare Advantage Plus or Medicare Part C Medicare Coverage and Eligibility Medicare Providers Part A Providers Part B Providers Participating vs. Non-participating Limiting Charge Determining the Medicare Fee and Limiting Charge Patient Registration Copying the Medicare Card Obtaining Patient Signatures Determining Primary or Secondary Payer Plans Primary to Medicare Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) Disabled End-stage Renal Disease (ESRD) Workers, Compensation Automobile, No-Fault and Liability Insurance Veteran Benefits Medicare Coordination of Benefits Contractor (COB) Hospital Registration Medicare as the Secondary Payer Medigap, Medicaid and Supplemental Insurance Conditional Payment Medicare Documents Development Letter Medicare Insurance Billing Requirements HCPCS Completing Medicare Part B Claims Form Locators for Medicare Part B Claims Railroad Retirement O MEDICARE Local Coverage Determination (LCD) Medicare Remittance Notice CMS-1500 FORM - Form Locator 29 Determining Medicare Fraud and Abuse Common types of Medicare abuse CHAPTER 12: MEDICAID Medicaid Guidelines Eligibility Groups Categorically Needy Medically Needy Immigrants TANF State Children,s Health Insurance Program (SCHIP or CHIP) Scope of Medicaid Services PACE Amount and Duration of Medicaid Services Payment for Medicaid SErvices Medicaid Summary and Trends The Medicaid- Medicare Relationship (Medi-Medi) Medicaid Managed Care Medicaid Verification Medicaid Claims Filing Time Limits for Submitting Claims Exceptions to the 95-Day Filing Deadline Appeal Time Limits Claims with Incomplete Information and Zero Paid Claims Newborn Claim Hints Completing the CMS-1500 for Medicaid (Primary) CHAPTER 13: TRICARE Tricare Fiscal Year Authorized Providers Preauthorization Tricare Standard Non-availability statement (NAS) Tricare Prime Tricare Prime Remote (TPR) Tricare EXTRA Tricare Senior Prime Tricare for Life CHAMPVA Submitting Claims to Tricare Completing the CMS-1500 for Tricare (Primary) Timely Filing Confidential and Sensitive Information Penalties and Interest Charges Section VI: Accounts Receivable CHAPTER 14: EXPLANATION OF BENEFITS AND PAYMENT ADJUDICATION Steps for Filing a Medical Claim Claim Process Adjudication Determining the Fees Charge-based fee structures Resource-based fee structures History of the RBRVS Resource Based Relative Value Scale (RBRVS) Determining the Medicare Fee Allowed Charge Payers Policies Capitation Calculations of Patient Charges Deductible Copayments Coinsurance Excluded Services Balance Billing Processing an EOB Information On An EOB Using Claims Information Adjustments to Patient Accounts Processing Reimbursement Information Determining the Amount Paid/Adjustments/Patient Due Methods of Receiving Funds Check by Mail Electronic Funds Transfer (EFT) Lock Box Services CHAPTER 15: REFUNDS AND APPEALS Reimbursement Follow-up Rebilling Denied or Delayed Payments Answering Patients, Questions about Claims Claim Rejection Appeal Peer Review State Insurance Commissioner Carrier Audits Documentation SOAP (Format of Record Keeping) Documentation Guidelines Registering a Formal Appeal Reason Codes That Require A Formal Appeal The Employee Retirement Income Security Act of 1974(ERISA) Waiting Period For An ERISA Claim Appeal to ERISA Medicare Appeals Redetermination Second Level of Appeal Third Level of Appeal and Beyond Necessity of Appeal Closing Words Appealing Denied Claims Do Not Settle for "Denial Upheld" Refund Guidelines Avoid Excessive Overpayments Guide to Insurance Overpayments and Refund Requests. Section VII: Injured Employee Medical Claim CHAPTER 16: WORKERS, COMPENSATION History of Workers, Compensation Federal Workers, Compensation Programs State Workers, Compensation Plans Overview of Covered Injuries, Illness, and Benefits Occupational Diseases Work-Related Injury Classifications Injured Worker Responsibilities and Rights Treating Doctor,s Responsibilities Selecting a Designated Doctor and Scheduling an Appointment Communicating With the Designated Doctor What the Designated Doctor Will Do Disputing the Designated Doctor's Findings Maximum Medical Improvement and Impairment Disputing Maximum Medical Improvement or Impairment Rating Ombudsmen Types of Workers, Compensation Benefits Medical Benefits Income Benefits Death and Burial Benefits Eligible Beneficiaries Dependent Child, Grandchild, and Other Eligible Parties Benefits and Compensation Termination Disability Compensation Programs Types of Government Disability Policies Verifying Insurance Benefits Preauthorization Requirements For The Preauthorization Request Filing Insurance Claims Completing the CMS-1500 for Workers, Compensation Claims Independent Review Organizations How to Obtain an Independent Review The IRO Decision Medical Records Fraud Penalties Medical Provider Fraud Calculate Reimbursement Section VIII: Computer Application CHAPTER 17: MEDICAL CLAIMS PROCESSING Simulation Instructions Tips for Entering Information into Medical Practice Management (MPM) Software Appendix A: Completing the CMS-1500 Form (08/05): Case Studies Appendix B: Completing the CMS-1500 Form and Determining the Diagnostic Code: Case Studies Appendix C: Medical Forms Appendix D: Completing the UB-04 Form: Case Studies Appendix E: Abbreviations Appendix F: Medical Terminology Word Parts Appendix G: Helpful Websites Appendix H: HIPAA Regulations Appendix I: Payment Posting Using Advanced NDC Medisoft (v. 12) Glossary Bibliography