Rent 9781401895952 | Understanding Health Insurance : A Guide to Billing and Reimbursement

Summary Table of Contents

Understanding Health Insurance: A Guide to Billing and Reimbursement, 8th Edition is a comprehensive source for teaching the subject of health insurance and reimbursement. The book contains chapters on introductory information on the health insurance field, managed health care, legal and regulatory issues, coding systems, reimbursement methodologies, coding for medical necessity, and common health insurance plans. Each chapter contains exercises to illustrate content and reinforce learning. Numerous opportunities are provided throughout the boo... MORE

List of Tables

Preface

xiii

How to Use This Text

xix

How to Use the Student Practice CD-ROM

xxi

... MORE

Health Insurance Specialist Career

(12)

Health Insurance Overview

(2)

Education and Training

(1)

Job Responsibilities

(4)

Professional Credentials

(4)

Introduction to Health Insurance

(16)

What Is Health Insurance?

(1)

Automobile, Disability, and Liability Insurance

(3)

Major Developments in Health Insurance

(1)

Health Insurance Coverage Statistics

(11)

Managed Health Care

(18)

History of Managed Health Care

(4)

Managed Care Organizations

(4)

Six Managed Care Models

(3)

Consumer-Directed Health Plans

(1)

Accreditation of Managed Care Organizations

(2)

Effects of Managed Care on a Physician's Practice

(4)

Life Cycle of an Insurance Claim

(40)

Insurance Claim Life Cycle

(12)

Managing New Patients

(8)

Managing Established Patients

(1)

Managing Office Finances

(4)

Maintaining Insurance Claim Files

(3)

Credit and Collections

(12)

Legal and Regulatory Issues

(36)

Introduction to Legal and Regulatory Considerations

(5)

Federal Laws and Events That Affect Health Care

(7)

Retention of Records

100

(1)

Medical Necessity

100

(1)

Health Insurance Portability and Accountability Act

100

(23)

ICD-9-CM Coding

123

(62)

Overview of ICD-9-CM

125

(2)

Outpatient Coding Guidelines

127

(4)

ICD-9-CM Coding System

131

(4)

ICD-9-CM Index to Diseases

135

(5)

ICD-9-CM Tabular List (Diseases)

140

(8)

Index to Procedures and Tabular List

148

(1)

ICD-9-CM Index to Diseases Tables

149

(11)

Supplementary Classifications

160

(3)

Coding Special Disorders

163

(4)

Considerations to Ensure Accurate ICD-9-CM Coding

167

(1)

ICD-10-CM: Diagnostic Coding for the Future

168

(17)

CPT Coding

185

(62)

Overview of CPT

186

(6)

CPT Categories, Subcategories, and Headings

192

(3)

CPT Index

195

(3)

CPT Modifiers

198

(10)

Coding Procedures and Services

208

(2)

Surgery Section

210

(9)

Medicine Section

219

(1)

Radiology Section

220

(2)

Pathology/Laboratory Section

222

(3)

Evaluation and Management Section

225

(9)

Evaluation and Management Subsections

234

(13)

HCPCS Coding

247

(12)

Overview of HCPCS

248

(1)

HCPCS Level II National Codes

249

(6)

Determining Payer Responsibility

255

(1)

Assigning HCPCS Level II Codes

256

(3)

CMS Reimbursement Methodologies

259

(24)

Historical Perspective of CMS Reimbursement Systems

260

(1)

CMS Payment Systems

260

(1)

Ambulance Fee Schedule

261

(1)

Ambulatory Surgical Center Rates

262

(1)

Clinical Laboratory Fee Schedule

263

(1)

Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule

264

(1)

Home Health Prospective Payment System

265

(1)

Hospital Inpatient Prospective Payment System

265

(3)

Hospital Outpatient Prospective Payment System

268

(1)

Inpatient Psychiatric Facility Prospective Payment System

269

(1)

Inpatient Rehabilitation Facility Prospective Payment System

269

(2)

Long-Term Care Hospital Prospective Payment System

271

(1)

Skilled Nursing Facility Prospective Payment System

272

(1)

Medicare Physician Fee Schedule

273

(10)

Coding for Medical Necessity

283

(30)

Coding and Billing Considerations

288

(3)

Coding from Case Scenarios

291

(3)

Coding from Patient Records

294

(19)

Essential CMS-1500 Claim Instructions

313

(24)

Insurance Billing Guidelines

317

(2)

Optical Scanning Guidelines

319

(3)

Recovery of Funds from Responsible Payers

322

(1)

Provider Identification Numbers

323

(1)

Assignment of Benefits versus Accept Assignment

324

(1)

Reporting Diagnoses: ICD-9-CM Codes

324

(1)

Reporting Procedures and Services: HCPCS/CPT

325

(3)

National Standard Employer Identifier Number

328

(1)

Reporting the Billing Entity

329

(1)

Processing Secondary Claims

330

(1)

Common Errors That Delay Processing

331

(1)

Final Steps in Processing Claims

332

(1)

Maintaining Insurance Claim Files for the Practice

332

(5)

Commercial Insurance

337

(18)

Commercial Claims

338

(1)

Claims Instructions

339

(10)

Commercial Secondary Coverage

349

(6)

Blue Cross and Blue Shield Plans

355

(28)

History of Blue Cross and Blue Shield

356

(4)

Blue Cross/Blue Shield Plans

360

(4)

Billing Information Summary

364

(2)

Claims Instructions

366

(8)

BCBS Secondary Coverage

374

(9)

Medicare

383

(46)

Medicare Eligibility

385

(1)

Medicare Enrollment

386

(2)

Original Medicare Plan

388

(2)

Medicare Part C

390

(1)

Medicare Part D

391

(1)

Medigap

392

(1)

Participating Providers

393

(1)

Nonparticipating Provider Restrictions

394

(2)

Surgical Disclosure Notice

396

(1)

Mandatory Claims Submission

397

(1)

Private Contracting

398

(1)

Advance Beneficiary Notice

398

(2)

Experimental and Investigational Procedures

400

(1)

Medicare as a Secondary Payer

400

(4)

Medicare Summary Notice

404

(1)

Billing Notes

404

(3)

Claims Instructions

407

(9)

Medicare with Medigap Claims

416

(1)

Medicare-Medicaid Crossover Claims

417

(1)

Medicare Secondary Payer Claims

418

(3)

Roster Billing for Mass Vaccination Programs

421

(8)

Medicaid

429

(26)

Medicaid Eligibility

430

(4)

Medicaid Covered Services

434

(2)

Payment for Medicaid Services

436

(4)

Billing Information Notes

440

(2)

CMS-1500 Claims Instructions

442

(7)

Medicaid as Secondary Claims

449

(1)

Mother/Baby Claims

450

(5)

Tricare

455

(30)

Tricare Background

456

(3)

Tricare Administration

459

(1)

Champva

460

(1)

Tricare Options

461

(4)

Tricare Programs and Demonstration Projects

465

(1)

Tricare Supplemental Plans

466

(1)

Tricare Billing Information

467

(3)

Claims Instructions

470

(8)

Primary Tricare with a Supplemental Policy

478

(1)

Tricare as Secondary Payer

478

(7)

Workers' Compensation

485

(152)

Federal Workers' Compensation Programs

486

(2)

State Workers' Compensation Program

488

(1)

Eligibility for Coverage

489

(1)

Classification of Workers' Compensation Cases

489

(1)

Special Handling of Workers' Compensation Cases

490

(1)

Workers' Compensation and Managed Care

491

(1)

First Report of Injury

491

(3)

Progress Reports

494

(2)

Appeals and Adjudication

496

(1)

Fraud and Abuse

496

(1)

Billing Notes

496

(2)

Claims Instructions

498

(11)

Appendices

Appendix I Case Studies: Set One

509

(22)

Appendix II Case Studies: Set Two

531

(48)

Appendix III Forms

579

(8)

CMS-1500 Claim

580

(1)

Coding Case Study Form

581

(1)

Insurance Plan Comparison Chart

582

(1)

E/M Codebuilder

583

(4)

Appendix IV Answers to Coding Exercises

587

(12)

Answers to ICD-9-CM Coding Exercises (Chapter 6)

587

(3)

Answers to CPT Coding Exercises (Chapter 7)

590

(3)

Answers to HCPCS Coding Exercises (Chapter 8)

593

(1)

Answers to Coding for Medical Necessity Exercises (Chapter 10)

594

(5)

Appendix V UB-92

599

(18)

Appendix VI Dental Claims Processing

617

(10)

Appendix VII Abbreviations

627

(4)

Appendix VIII Common Medical Terminology: Prefixes, Suffixes, and Combining Forms

631

(2)

Appendix IX Web Sites

633

(4)

Bibliography

637

(4)

Glossary

641

(22)

Index

663

(30)

Using the Student Practice CD-ROM

693

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Understanding Health Insurance : A Guide to Billing and Reimbursement

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