Insurance Coding and Electronic Claims for the Medical Office

by Safian, Shelley

• ISBN13: 9780073053073
• ISBN10: 0073053074
• Edition: 1st
• Format: Package
• Copyright: 2005-07-07
• Publisher: McGraw-Hill Education

Summary

This text is structured to reflect a day in the life of an insurance codding and billing specialist. Using a "layered learning" concept, the student will move through the book in a logical progression, building upon each element learned at each stage of the reimbursement process. Students will learn to carefully glean pertinent data to code accurately from review and analysis of: a.) Superbills, b.) Provider's notes, c.) Referral authorization forms, and d.) New patient information forms.

Table of Contents

Preface	viii
Insurance Overview	1	(14)
The Participants	3	(1)
Key Types of Insurance Plans	3	(5)
Health Maintenance Organization (HMO)	3	(1)
Preferred Provider Organization (PPO)	4	(1)
Point-of-Service (POS) Plan	4	(1)
Centers for Medicare & Medicaid Services (CMS)	4	(1)
TriCare/Champus/Champva	5	(1)
Other Insurance Plans	6	(2)
Methods of Payment to Your Office	8	(4)
Fee-for-Service (FFS) Plans	8	(1)
Capitation Plans	9	(1)
Episodic Care	9	(1)
Individual Insurance Contributions	10	(2)
Chapter Review	12	(3)
HIPAA's Privacy Rule Overview	15	(17)
Who Is Responsible for Obeying This Law	16	(1)
What This Law Covers	17	(11)
The Use and Disclosure of PHI	19	(1)
Getting Written Approval	20	(2)
Permitted Uses and Disclosures	22	(2)
Privacy Notices	24	(1)
Violating HIPAA's Privacy Rule	25	(3)
Chapter Review	28	(4)
Source Documents	32	(30)
Patient Registration Form	33	(7)
Insurance Card	40	(2)
Referral Authorization Form	42	(3)
Encounter Form and Superbill	45	(2)
Physician's Notes	47	(13)
Using Physician's Notes to Support Medical Necessity	49	(1)
Learning How to Understand Physician's Notes	49	(3)
Styles of Physician's Notes	52	(8)
Chapter Review	60	(2)
Introduction to Coding---Guidelines Overview	62	(19)
Seven Steps to Accurate Coding	63	(1)
Coding from Superbills Instead of Physician's Notes	64	(5)
ICD-9-CM Official Guidelines for Coding and Reporting	69	(1)
CPT Procedure Coding Guidelines	70	(1)
Rules for Ethical and Legal Coding	71	(7)
Chapter Review	78	(3)
Coding Diagnoses: ICD-9-CM	81	(37)
Getting Ready to Code	83	(3)
Three Categories of ICD-9-CM Diagnostic Codes	86	(4)
ICD-9-CM Codes	86	(1)
V Codes	86	(2)
E Codes	88	(2)
Three, Four, or Five Numbers---How Do You Know?	90	(6)
Three Digits	90	(1)
Four Digits	91	(1)
Five Digits	92	(4)
What to Code or Not Code	96	(7)
Notations and Explanations	103	(1)
Multiple and Additional Codes	103	(2)
Tables in the Alphabetic Listings (Volume 2)	105	(8)
Hypertension Table	105	(3)
Neoplasm Table	108	(3)
Table of Drugs & Chemicals	111	(2)
Too Much to Remember?	113	(2)
Chapter Review	115	(3)
Coding Diagnoses: ICD-10-CM	118	(14)
Introduction to ICD-10-CM	119	(1)
The Look of ICD-10-CM Codes	120	(1)
Length of Codes	120	(1)
Types of Characters	120	(1)
ICD-10-CM Code Descriptions	120	(8)
More Detailed Descriptions	120	(2)
Combination Codes	122	(1)
Z Codes---Formerly Known as V Codes	122	(1)
E (External) Codes	123	(1)
Notations and Explanations	123	(4)
ICD-10-CM Dummy Place Holders and Additional Characters	127	(1)
Complete ICD-10-CM Coding Guidelines	128	(2)
Chapter Review	130	(2)
Coding Procedures: CPT	132	(33)
Numerical Listings of CPT Codes	133	(1)
Coding and Reporting Guidelines	133	(1)
Alphabetic Index	133	(1)
Evaluation and Management Codes	134	(7)
Location	135	(1)
Relationship	135	(1)
Complexity/Time	136	(3)
Reading the Physician's Notes	139	(2)
The Numeric Listings in CPT	141	(5)
CPT Formatting	141	(1)
CPT Directional Symbols	142	(1)
CPT Directional Notations	143	(2)
CPT Instructional Notations	145	(1)
Using Documentation to Determine Procedure Codes	146	(5)
Modifiers	151	(8)
Evaluation and Management Modifiers	152	(1)
Surgical Modifiers	152	(2)
Procedure Modifiers	154	(1)
Laboratory Modifiers	155	(1)
Multiple Modifiers	156	(1)
Anesthesia Physical Status Modifiers	157	(1)
Modifiers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use	158	(1)
Category III Codes	159	(1)
Unlisted Codes	160	(1)
The Surgical Package	161	(2)
Chapter Review	163	(2)
Coding Procedures: ICD-9-CM Volume 3 and ICD-10-PCS	165	(17)
ICD-9-CM Volume 3	166	(7)
How Codes Are Structured	166	(1)
Coding Procedures Using ICD-9-CM, Volume 3	166	(7)
ICD-10-PCS	173	(6)
The Objectives for ICD-10-PCS	173	(1)
Notations in ICD-10-PCS	174	(1)
The Structure of ICD-10-PCS Codes	174	(1)
The ICD-10-PCS Book	175	(1)
ICD-10-PCS Character Order and Place Holders	176	(3)
Chapter Review	179	(3)
Complete Coding Practice: ICD-9-CM and CPT	182	(10)
Linking Diagnosis and Procedure Codes	183	(2)
Coding Practice	185	(7)
Physician's Notes for Marvin Doe	185	(1)
Physician's Notes for Roger Samuels	186	(1)
Physician's Notes for Patience Loyal	186	(1)
Physician's Notes for Wayne Johns	187	(1)
Physician's Notes for Mary Lou Sweet	187	(1)
Physician's Notes for Naomi Morgan	188	(1)
Physician's Notes for Harvey Practice	188	(1)
Physician's Notes for Marion Maxwell	189	(1)
Physician's Notes for Sarah Student	189	(1)
Physician's Notes for Paul Pepperstone	190	(1)
Physician's Notes for Mitzi Cagwell	190	(1)
Physician's Notes for Tex T. Books	191	(1)
Physician's Notes for Joan Smith-Doe	191	(1)
Health Insurance Claim Form CMS-1500	192	(26)
CMS-1500	193	(21)
Section 1: Top Left	193	(6)
Section 2: Top Right	199	(3)
Section 3: Bottom Left	202	(8)
Section 4: Bottom Right	210	(4)
UB-92 Form	214	(2)
Chapter Review	216	(2)
Electronic Claims Management: Using Patient Accounting Software	218	(69)
Benefits and Challenges of Electronic Claims Processing	219	(2)
One Mistake Can Equal a Thousand Errors	219	(1)
A Name Is Not a Name---Spelling Matters	219	(1)
One Number Off Is a Whole New Code	220	(1)
Types of Patient Accounting Software Programs	221	(1)
Entering Patient Data Using NDCMedisoft™ Advanced	222	(43)
Creating a New Practice	222	(2)
Entering a New Insurance Carrier	224	(2)
Entering a Patient's Employer	226	(2)
Entering Diagnosis Codes	228	(1)
Entering Procedure Codes	229	(4)
Practicing What You've Learned on Your Computer	233	(1)
Entering Attending Providers	233	(2)
Entering Referring Providers	235	(3)
Entering a New Patient	238	(5)
Entering a New Case	243	(9)
Entering Procedures and Patient Co-Payments	252	(5)
Printing a Receipt	257	(3)
Creating a Health Insurance Claim Form	260	(5)
Sending Claims Electronically	265	(11)
Chapter Review	276	(11)
Working with Insurance Companies	287	(15)
Working with Clearinghouses	288	(1)
Organizing Claims	289	(12)
Pile 1: Claims That Have Been Paid by the Insurers	290	(1)
Pile 2: Claims for Which You Have Received Denial Notices	291	(8)
Pile 3: Claims for Which You Have Received No Notices or Payment	299	(2)
Chapter Review	301	(1)
Receiving Revenues	302	(16)
Remittance Advice Review	303	(4)
Entering Insurance Payments into NDCMedisoft™ Advanced, Version 9	307	(7)
Capitation Payments	314	(2)
Chapter Review	316	(2)
Complete Coding and Claims Practice	318	(18)
Part I: Coding Practice	319	(11)
Bette Brothenheim	320	(2)
Scotty Mathison	322	(2)
Elise Dawson	324	(2)
Gregory H. Zolman	326	(2)
Halle A. Jackson	328	(2)
Part II: Claims Practice	330	(6)
Appendix A Abbreviations	336	(11)
Appendix B ICD-9-CM Official Guidelines for Coding and Reporting	347	(50)
Appendix C 1997 Documentation Guidelines for Evaluation and Management Services	397	(29)
Appendix D NDCMedisoft™ Advanced, Version 9---Issues and Answers	426	(6)
Glossary	432	(5)
Index	437