Comprehensive Health Insurance: Billing, Coding, and Reimbursement [With CDROM] / Edition 1

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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.
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Product Details

  • ISBN-13: 9780132368155
  • Publisher: Prentice Hall
  • Publication date: 3/10/2008
  • Series: Pearson Custom Health Professions Series
  • Edition description: Older Edition
  • Edition number: 1
  • Pages: 960
  • Product dimensions: 8.50 (w) x 10.70 (h) x 1.30 (d)

Meet the Author

Deborah Vines has worked extensively for over 20 years in the healthcare industry as a Practice Administrator and Manager in physical therapy, dermatopathology and pediatrics. She has also held management positions in the hospital setting. As Director of Operations for a national healthcare staffing corporation, she has traveled across the United States, working directly with physicians and medical human resources to secure jobs for individuals in the medical billing, coding and collection fields. A mentionable achievement of Ms. Vines’ is in one fiscal year she assisted 300 recruits find employment in this industry through mentoring and training. This achievement led her to open a successful vocational school specializing in medical office specialist training.

Ann B. Braceland has been working in the medical field since graduation from Gwynedd Mercy College is 1964 with an associate's degree in nursing. As a practice manager she has demonstrated the ability to adopt to changes to the challenges that arise in medical billing, coding and managed care contracts. Mrs. Braceland has established and managed offices in Physical Medicine and Occupational Medicine. These experiences led her to teaching skills. She is now highly regarded for training physicians and medical personnel in compliance coding, billing as well as medical office management. She was a Medicare representative and Director of Training of Allied Career School in Dallas, TX. Her teaching and lectures has formed the basis of this subsequent text.

Elizabeth Rollins, NCICS began her career in a nationally renowned multi-office pediatric ophthalmology practice. She worked in every position, from medical receptionist and appointment scheduling, to medical records and insurance claims submission, before being promoted to Insurance/Collection Manager. She completed insurance claims by hand and typed the patient billing statements for four years until the practice became computerized. As a Certified Account Manager for a national healthcare staffing corporation, Elizabeth met with hospitals, physicians, clinics and CBOs to assess their employment needs and showcase her roster of employees ready for hire. Elizabeth is a National Certified Insurance and Coding Specialist as well as the Director and an Instructor at a vocational school where she enjoys meeting with, teaching and encouraging students on a daily basis.

Susan Miller, NCICS has 20 years experience in the medical field and currently specializes in dialysis billing. She was previously a Lead Instructor at a vocational school, preparing students for a career in the medical field as medical office specialists. She has acted as a supervisor at insurance companies and worked one-on-one with policyholders to assist them in having a better understanding of health insurance. In 2004 she obtained the title of National Certified Insurance & Coding Specialist. She also holds certificates from Career Colleges and schools of Texas and Brookhaven College for Interactive Leadership Skills for Educators.

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Table of Contents


Section I — A Career in Healthcare


Employment Demand


Physician Practice


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


Medical Office Assistant Certification

Medical Billing Certifications

Medical Coding Certifications

Medical Records Certification


Section II: Relationship between the Patient, Provider and Carrier


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 Indemnity Insurance

Medical Surgical


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



Patient Care

Facility Operations

Collection of Funds

Assignment of Benefits


Purpose of a Contract

A Legal Agreement

Compensation and Billing Guidelines Covered Medical Expenses


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


Definitions of Diagnosis Coding

History of Diagnosis Coding

Purpose of ICD-9-CM


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



Injuries, Complications and Accidents


Other Scenarios

Nine Steps for Accurate ICD-9-CM Coding



CPT Categories

Category I

Category II

Category III

CPT Nomenclature




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



Level of E/M Service

Extent of Patient’s History

Extent of Examination

Complexity of Medical Decision Making

Additional Components

Assigning the Code


Organization of the CPT Index Instructions for Using the CPT

Format of the Terminology



Section Guidelines


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



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


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


How to be Compliant

Benefits of a Voluntary Compliance Program

Ethics for the Medical Coder



External Audit

Internal Audit

Purpose of an Audit

Private Payer Regulations

Medical Necessity for E/M Services

Audit Tool

Key Elements of Service



Medical Decision Making

Tips for Preventing Coding Errors with Specific E/M Codes

Section IV: Medical Claims


Patient Information


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


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


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)


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


Completing Medicare Part B Claims

Form Locators for Medicare Part B Claims

Railroad Retirement


Local Coverage Determination (LCD)

Medicare Remittance Notice

CMS-1500 FORM — Form Locator 29

Determining Medicare Fraud and Abuse

Common types of Medicare abuse


Medicaid Guidelines

Eligibility Groups

Categorically Needy

Medically Needy



State Children’s Health Insurance Program (SCHIP or CHIP)

Scope of Medicaid Services


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)



Fiscal Year

Authorized Providers


Tricare Standard

Non-availability statement (NAS)

Tricare Prime

Tricare Prime Remote (TPR)

Tricare EXTRA

Tricare Senior Prime Tricare for Life


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


Steps for Filing a Medical Claim

Claim Process


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


Calculations of Patient Charges




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


Reimbursement Follow-up


Denied or Delayed Payments

Answering Patients’ Questions about Claims

Claim Rejection Appeal

Peer Review State Insurance Commissioner Carrier Audits


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


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


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


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


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



Medical Provider Fraud

Calculate Reimbursement

Section VIII: Computer Application


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)



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