Rent 9781401837914 | Understanding Health Insurance : A Guide to Professional Billing

Summary Table of Contents

Understanding Health Insurance: A Guide to Professional Billing, 7th edition, is a comprehensive guide for those learning about health insurance claims processing and reimbursement issues. The text utilizes a step-by-step approach to successful completion of health insurance claims. The objectives of this edition are to 1) introduce information about major third party payers, 2) provide up-to-date information about federal health care regulations, 3) clarify coding guidelines and provide application exercises for each coding system, 4) introduc... MORE

List of Tables

viii

Preface

Chapter 1 Health Insurance Specialist-Roles and Responsibilities

(14)

Health Insurance Overview

(2)

... MORE

(4)

Health Insurance Specialist Responsibilities

(1)

Professional Credentials

Chapter 2 Introduction to Health Insurance

(16)

What is Health Insurance?

(1)

Disability and Liability Insurance

(2)

Major Developments in Health insurance

(7)

Health Insurance Coverage Statistics

(6)

Chapter 3 Managed Health Care

(20)

History of Managed Health Care

(2)

Managed Care Organizations

(5)

Six Managed Care Models

(4)

Accreditation of Managed Care Organizations

(1)

Effects of Managed Care on a Physician's Practice

(8)

Chapter 4 Life Cycle of an Insurance Claim

(30)

Development of the Claim

(1)

New Patient Interview and Check-In Procedure

(9)

Established Patient Return Visit

(1)

Postclinical Check-Out Procedures

(5)

Insurance Company Processing of a Claim

(3)

Maintaining Insurance Claim Files

(5)

Delinquent Claims

(6)

Chapter 5 Legal and Regulatory Considerations

(36)

Introduction to Legal and Regulatory Considerations

(4)

Confidentiality of Patient Information

(6)

Claims Information Telephone Inquiries

(1)

Facsimile Transmission

(1)

Confidentiality and the Internet

(1)

Retention of Patient Information and Health Insurance Records

(1)

Employee Retirement Income Security Act (ERISA)

(1)

Medical Necessity

(1)

Federal False Claims Act

(1)

Health Insurance Portability and Accountability Act of 1996

(21)

Chapter 6 ICD-9-CM Coding

117

(66)

Introduction to ICD-9-CM

118

(1)

Outpatient Coding Guidelines

119

(3)

Primary and Principal Diagnoses

122

(2)

Principal versus Secondary Procedures

124

(1)

Coding Qualified Diagnoses

125

(1)

ICD-9-CM Coding System

126

(4)

ICD-9-CM Index to Diseases

130

(2)

Basic Steps for Using the Index to Diseases

132

(4)

ICD-9-CM Tabular List of Diseases

136

(7)

Index to Procedures and Tabular List of Procedures

143

(1)

ICD-9-CM Index to Diseases Tables

144

(11)

Supplementary Classifications

155

(4)

Coding Special Disorders

159

(4)

Considerations to Ensure Accurate ICD-9-CM Coding

163

(1)

ICD-10-CM: Diagnostic Coding for the Future

164

(19)

Chapter 7 CPT Coding

183

(68)

CPT Coding System

184

(5)

CPT Categories, Subcategories, and Headings

189

(4)

CPT Index

193

(3)

CPT Modifiers

196

(11)

Basic Steps for Coding Procedures and Services

207

(1)

Surgery Section

208

(5)

Coding Special Surgery Cases

213

(4)

Medicine Section

217

(1)

Radiology Section

218

(2)

Pathology/Laboratory Section

220

(4)

Evaluation and Management Section

224

(11)

Evaluation and Management Categories

235

(16)

Chapter 8 HCPCS Coding System

251

(20)

HCPCS Coding System

252

(1)

HCPCS Level 11 Codes

253

(12)

Determining Carrier Responsibility

265

(1)

Assigning HCPCS Level II Codes

266

(5)

Chapter 9 CMS Reimbursement Issues

271

(10)

Historical Perspective of CMS Reimbursement Systems

272

(1)

CMS Payment Systems

272

(1)

Ambulance Fee Schedule

273

(1)

Ambulatory Surgical Centers (ASC)

274

(1)

Clinical Lab Diagnostic Fee Schedule

275

(1)

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

275

(1)

Home Health Prospective Payment System

275

(1)

Hospital Inpatient Prospective Payment System

276

(1)

Inpatient Rehabilitation Facility Prospective Payment System

277

(1)

Long-Term Care Hospitals Prospective Payment System

277

(1)

Skilled Nursing Facility (SNF) Prospective Payment System

278

(1)

Medicare Physician Fee Schedule

278

(1)

Anesthesia, Pathology/Laboratory, and Radiology Services

278

(3)

Chapter 10 Coding for Medical Necessity

281

(30)

Applying Coding Guidelines

288

(5)

CPTIHCPCS Billing Considerations

293

(1)

Coding from Case Scenarios

293

(4)

Coding from Clinic Notes and Diagnostic Test Results

297

(5)

Coding Operative Reports

302

(9)

Chapter 11 Essential CMS-1500 Claim Instructions

311

(28)

General Billing Guidelines

318

(3)

Optical Scanning Guidelines

321

(3)

Assignment of Benefits/Accept Assignment

324

(1)

Reporting Diagnoses: ICD-9-CM Codes

324

(1)

Reporting Procedures and Services: HCPCS

325

(5)

National Standard Employer Identifier Number

330

(1)

Reporting the Billing Entity

331

(1)

Processing Secondary Claims

331

(2)

Common Errors That Delay Processing

333

(1)

Final Steps in Processing Paper Claims

333

(1)

Maintaining insurance Claim Files for the Practice

334

(5)

Chapter 12 Filing Commercial Claims

339

(26)

Commercial Claims

340

(1)

Step-by-Step Claim Instructions-Blocks 1-13 Entering Patient and Policy Information

341

(7)

Step-by-Step Claim Instructions-Blocks 14-23 Dates of Service and Diagnosis Codes

348

(2)

Step-by-Step Claim Instructions-Block 24 Procedures, Services, and Supplies

350

(4)

Step-by-Step Claim Instructions-Blocks 25-33 Provider Information

354

(3)

Commercial Secondary Coverage

357

(1)

Modifications to Primary CMS-1500 Claims

357

(1)

Modifications to Secondary CMS-1500 Claims

358

(7)

Chapter 13 Blue Cross and Blue Shield Plans

365

(36)

History of Blue Cross and Blue Shield

366

(4)

Blue Cross Blue Shield Plans

370

(6)

Billing Information Summary

376

(1)

Step-by-Step Claim Instructions

377

(13)

BCES Secondary Coverage

390

(11)

Chapter 14 Medicare

401

(64)

Medicare Eligibility

402

(1)

Medicare Enrollment

403

(2)

Medicare Part A Coverage

405

(3)

Medicare Part B Coverage

408

(2)

Participating Providers

410

(1)

Nonparticipating Providers

411

(4)

Private Contracting

415

(1)

Advance Beneficiary Notice

416

(1)

Medicare as a Secondary Payer

417

(4)

Medicare Plans

421

(10)

Billing Notes

431

(1)

Step-by-Step Claim Instructions

432

(16)

Medicare with Medigap Claims

448

(4)

Medicare-Medicaid Crossover Claims

452

(1)

Medicare Secondary Payer (MSP) Claims

452

(3)

Roster Billing for Mass Vaccination Programs

455

(10)

Chapter 15 Medicaid

465

(34)

Federal Eligibility Requirements for Medicaid

466

(3)

Medicaid Covered Services

469

(4)

Medicare-Medicaid Relationship

473

(1)

Medicaid as a Secondary Payer

474

(1)

Participating Providers

474

(1)

Medicaid and Managed Care

474

(1)

Medicaid Eligibility Verification System (MEVS)

474

(1)

Medicaid Remittance Advice

475

(1)

Utilization Review

476

(1)

Fraud and Abuse

476

(1)

Medial Necessity

476

(1)

Billing Information Notes

476

(2)

Step-by-Step Claim Instructions

478

(11)

Medicaid as Secondary Claims

489

(4)

Mother/Baby Claims

493

(6)

Chapter 16 Tricare

499

(34)

Tricare Background

500

(1)

Tricare Administration

500

(3)

CHAMPVA

503

(1)

Tricare Options

504

(4)

Tricare Programs and Demonstration Projects

508

(2)

Tricare Supplemental Plans

510

(1)

Tricare Billing Information

510

(3)

Tricare Primary Claim Instructions

513

(13)

Primary Tricare with a Supplemental Policy

526

(1)

Tricare as Secondary Payer

526

(7)

Chapter 17 Workers' Compensation

533

(30)

Federal Workers' Compensation Programs

534

(2)

State Workers' Compensation Program

536

(1)

Eligibility for Coverage

537

(1)

Classification of Workers' Compensation Cases

537

(2)

Special Handling of Workers' Compensation Cases

539

(1)

Workers' Compensation and Managed Care

539

(1)

First Report of Injury

540

(3)

Progress Reports

543

(2)

Appeals and Adjudication

545

(1)

Fraud and Abuse

545

(1)

Billing Information Notes

545

(2)

Workers' Compensation Claim Instructions-Patient and Policy Identification

547

(16)

Appendices

Appendix I

Case Studies: Set One

563

(22)

Appendix II

Case Studies: Set Two

585

(47)

Appendix III

Forms

632

(1)

CMS-1500 Claim

633

(1)

Coding Case Study Form

634

(1)

Insurance Plan Comparison Chart

635

(1)

E/M Codebuilder

636

(3)

Appendix IV

Answers to Coding Exercises

639

(1)

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

639

(2)

Answers to CPT Coding Exercises (Chapter 7)

641

(4)

Answers to Chapter 8 Exercises

645

(1)

Answers to Chapter 10 Exercises

645

Appendix V

Using the Student Practice CD-ROM

641

(9)

License Agreement for Delmar Learning

650

(1)

Appendix VI

UB-92

651

(6)

Bibliography

657

(2)

Glossary

659

(18)

Index

677

RENT TEXTBOOKS

Understanding Health Insurance : A Guide to Professional Billing

Why Rent from Knetbooks?

Top 5 reasons to order all your textbooks from Knetbooks:

Related Products