The Guide to Medical Billing and Coding

by Publishing Inc., ICDC

• ISBN13: 9780131722521
• ISBN10: 0131722522
• Edition: 2nd
• Format: Paperback
• Copyright: 2006-04-07
• Publisher: Pearson

Summary

This comprehensive text includes not only insurance billing and claims, but also office procedures. It provides a complete understanding of all the skills necessary to perform as a medical biller, including a review of medical terminology.

Table of Contents

Medical Practice Administration	p. 1
Introduction to Medical Billing and Coding	p. 3
Job Roles and Duties	p. 4
The Medical Team	p. 4
Types of Healthcare Settings	p. 5
Basic Skill Requirements of the Medical Biller	p. 6
Interpersonal Skills	p. 6
Stress	p. 8
Prevacation Work Planning	p. 9
Certification Programs for Medical Billers	p. 10
Legal Issues	p. 10
Fraud	p. 13
HIPAA and Fraud and Abuse	p. 14
Embezzlement	p. 15
Employee Bonding and Errors and Omission Insurance	p. 16
Claim Audits	p. 16
Medical Ethics	p. 16
Subpoenas	p. 17
Instances in Which the Patient Should Be Notified and the File Notated	p. 19
Clinical Records and Medical Documentation	p. 28
Medical Charts	p. 29
Filing the Chart	p. 31
Medical Documentation Rules	p. 32
SOAP Notes	p. 33
Signature Cards	p. 34
Retention of Records	p. 34
Storing Medical Records	p. 35
Electronic Medical Charting	p. 36
Computerized Files	p. 37
Record Transfers	p. 38
Patient Information Sheet	p. 39
Release of Information Form	p. 42
Assignment of Benefits Form	p. 46
Patient History Form	p. 46
Insurance Verification	p. 46
Additional Suggestions	p. 49
Health Insurance Programs	p. 55
Health Insurance Contract Interpretation	p. 57
Blue Cross/Blue Shield	p. 58
Contract Provisions	p. 58
Contract Benefits	p. 63
Exclusions	p. 72
Allowed Amounts	p. 72
Precertification of Inpatient Admissions	p. 73
Utilization Review	p. 73
Second Surgical Opinion Consultations	p. 74
Coordination of Benefits	p. 75
Medicare and Medicaid	p. 101
Medicare	p. 102
Medicare Eligibility	p. 102
The Parts of Medicare	p. 103
Allowable Charges	p. 104
Medicare Health Insurance Card (HIC)	p. 105
Medicare Physician Identification Numbers	p. 106
Medicare Billing Notices	p. 107
Assignment of Benefits	p. 112
Medicare Secondary Payer	p. 115
Diagnosis-Related Group Billing	p. 116
Durable Medical Equipment	p. 117
Medicare Denials	p. 117
Advance Beneficiary Notice (ABN)	p. 117
The Medicare Appeals Process	p. 120
Medicare Fraud and Abuse	p. 122
Medicare Supplemental Insurance	p. 125
Medicare and Managed Care	p. 125
Medicare Notice of Non-Coverage	p. 125
Medicare Billing Guidelines	p. 126
Medicaid	p. 126
Medicaid Covered Services	p. 128
Reimbursement from Medicaid	p. 129
Medicaid as Secondary Payer	p. 130
Treatment Authorization Request	p. 130
Medicaid Billing Guidelines	p. 133
Workers' Compensation	p. 140
Intent of the Workers' Compensation System	p. 141
Employee Activities	p. 142
Time Limits	p. 143
Fraud and Abuse	p. 143
Types of Workers' Compensation Benefits	p. 144
Treating Physicians	p. 146
Medical-Legal Evaluations	p. 146
Medical Service Order	p. 146
Patient Records	p. 147
Doctor's First Report of Injury/Illness	p. 147
Progress Reports	p. 151
Physician's Final Report	p. 151
Billing for Workers' Compensation Services	p. 152
Third-Party Liability	p. 153
Liens	p. 153
Delinquent Claims	p. 157
Delay of Adjudication	p. 157
Workers' Compensation Appeals	p. 157
Reversals	p. 157
Managed Care	p. 162
Rising Healthcare Costs	p. 163
Managed Care	p. 163
HMO Coverage	p. 165
Preferred Provider Organizations	p. 165
Self-Insurance	p. 167
Billing Managed Care Plans	p. 167
Groups/IPAs	p. 169
Capitation Payments	p. 172
Appointment Scheduling	p. 174
Authorizations, Referrals, and Second Opinions	p. 175
Denial of Services to Members	p. 177
Member Grievances and Complaints	p. 178
Transfers	p. 179
Disenrollment	p. 179
Continuing Care	p. 180
Miscellaneous Services	p. 181
Sanctions	p. 182
Claim Payments	p. 182
Finances and Accounting	p. 193
Medical Practice Accounting	p. 195
Patient Accounting	p. 196
Accounts Payable/Receivable	p. 196
Patient Ledger Card/Statement of Account	p. 196
Insurance Payments	p. 198
Patient Payments	p. 200
Posting Payments	p. 200
Balance Billing	p. 200
Follow-Ups	p. 201
Collections	p. 202
Collections Procedures	p. 204
Small Claims Court	p. 207
Practice Accounting	p. 208
Petty Cash	p. 208
The Day Sheet/Daily Journal	p. 209
Office Reports	p. 211
Medical Coding	p. 219
Reference Books	p. 221
ICD-9-CM	p. 222
CPT	p. 222
Medical Dictionary	p. 222
Merck Manual	p. 223
Physicians' Desk Reference	p. 223
HCPCS	p. 226
International Classification of Disease (ICD-9-CM) Coding	p. 245
History of the ICD-9-CM	p. 246
Contents of the ICD-9-CM	p. 246
How to Use the ICD-9-CM	p. 246
General Guidelines	p. 247
Main Terms	p. 248
Exceptions	p. 249
V Codes	p. 252
E Codes	p. 253
Signs and Symbols Used in the ICD-9-CM	p. 253
ICD-10-CM	p. 254
Current Procedural Terminology (CPT) Coding	p. 266
Using the CPT	p. 267
Semicolons in the CPT	p. 267
Signs and Symbols Used in the CPT	p. 268
Using the CPT Index	p. 268
Modifiers	p. 268
Unlisted Codes	p. 268
Evaluation and Management Codes	p. 268
Anesthesia	p. 271
Surgery	p. 275
Radiology/X-ray	p. 280
Pathology/Laboratory	p. 281
Medicine	p. 282
Medical Billing	p. 299
The CMS-1500 Form and Medical Billing Procedures	p. 301
Superbill	p. 302
CMS-1500 Block Explanations	p. 306
1500 Health Insurance Claim Form (Version 08/05)	p. 308
Patient Claim Form	p. 310
Billing for Services	p. 311
Incomplete Data Master List	p. 314
Determining the Proper Billing Amount	p. 315
Special Services	p. 316
Claims Submission Process	p. 316
Clean Claims	p. 318
Coordination of Benefits	p. 318
COB with Health Maintenance Organizations	p. 319
Collecting the Patient Portion	p. 320
Tricare	p. 321
Billing Reports	p. 323
Prompt Payment Laws	p. 323
Tracer Claims/Delinquent Claims	p. 325
Denied Claims	p. 325
Resubmission of Claims	p. 325
Adjusted Claims	p. 325
Review and Appeals	p. 326
Balance Billing Patients for Downcoded or Denied Claims	p. 326
State Insurance Commissioner	p. 326
Maximum Reimbursement Guidelines	p. 327
The UB-92 Form and Hospital Billing Procedures	p. 333
Field Locator # and Name/Description	p. 335
Uniform Bill (UB-04)	p. 339
Item 42, Hospital Revenue Codes	p. 339
Item 53, Assignment of Benefits	p. 342
Chargemaster Descriptions	p. 345
Entering Charges	p. 346
How Billing Affects Other Departments	p. 347
Preauthorization, Precertifications, and Utilization Reviews	p. 347
Ambulatory Surgical Centers	p. 348
Abstracting, Billing, and Coding from Medical Reports	p. 357
Abstracting from Medical Records	p. 358
Triage Reports	p. 358
Operative Reports	p. 358
Diagnostic Testing Reports	p. 358
Medical History and Physical Examination Reports	p. 358
General Office Procedures	p. 389
Basic Office Functions and Communications	p. 391
Mail	p. 392
Office Machines	p. 396
Tickler Files	p. 397
Practice Communication	p. 398
The Opening	p. 399
The Body	p. 399
The Closing	p. 399
Correspondence Containing Negative Content	p. 399
Format of the Letter	p. 400
Memos	p. 400
Patient Relations	p. 405
First Impressions and Image	p. 406
Customer Service Job Functions	p. 406
The Art of Listening	p. 407
Maintaining an Appointment Calendar	p. 411
Securing Employment	p. 421
Job Search Preparation	p. 423
Key Descriptions	p. 424
Printer Tape Symbols	p. 425
Computer Basics	p. 425
The Computer	p. 425
The Monitor	p. 427
The Keyboard	p. 428
Computer Terms	p. 430
Job Search Preparation	p. 433
Job Search Objectives	p. 433
Uniqueness	p. 433
Target Audience	p. 433
Build Your Database	p. 434
The Resume	p. 434
The Cover Letter	p. 436
Marketing Yourself	p. 437
The Job Interview	p. 438
Getting Paid What You Are Worth	p. 440
Appendices	p. 457
Provider and Medical Abbreviations	p. 459
Provider Abbreviations	p. 460
Medical Abbreviations	p. 461
Forms	p. 464
Patient Information Sheet	p. 465
Insurance Coverage Form	p. 467
Doctor's First Report of Occupational Injury or Illness	p. 468
Lien Letter	p. 469
Lien Form	p. 470
Insurance Tracer	p. 471
Encounter Form	p. 472
Patient Receipt	p. 473
Ledger Card/Statement of Account	p. 474
Day Sheet/Daily Journal	p. 475
Deposit Slip/Ticket	p. 476
Patient Claim Form	p. 477
Superbill/Charge Slip	p. 479
Insurance Claim Register	p. 480
CMS-1500 Claim Form	p. 481
UB-92 Billing Form	p. 482
Hospital Admission Form	p. 483
Domestic Return Receipt	p. 484
Certified Mail Form	p. 485
Ground Tracking ID COD Prepaid	p. 486
COD Airbill	p. 487
COD Shipper Receipt	p. 488
Ground Tracking ID Prepaid	p. 488
Airbill	p. 489
Stationery	p. 490
Envelope	p. 491
Tables	p. 492
Patient Data Table	p. 493
Provider Data Table	p. 494
Order of Benefit Determination	p. 495
Medicare Secondary Payer	p. 496
Quick Reference Codes	p. 497
Place of Service Codes	p. 501
Hospital Revenue Codes	p. 504
Hospital Form Locator Codes	p. 516
State Abbreviations	p. 521
Other Address Abbreviations	p. 522
CMS-1500/1500 Health Insurance Claim Form	p. 523
CMS-1500 Claim Form Matrix	p. 524
CMS-1500 Sample Claims	p. 543
1500 Health Insurance Claim Form	p. 548
UB-92 (CMS-1450)/UB-04	p. 550
UB-92 Form Matrix	p. 551
UB-92 Sample Claims	p. 576
UB-92 to UB-04 Crosswalk	p. 581
Glossary	p. 586
Credits	p. 595
Index	p. 597
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