Understanding Hospital Coding and Billing : A Worktext

by Diamond,Marsha S

• ISBN13: 9781401879433
• ISBN10: 1401879438
• Edition: 1st
• Format: Spiral Bound
• Copyright: 2006-07-03
• Publisher: Cengage Learning

Summary

Finally, a complete guide to the hospital coding and billing processes that includes both inpatient and outpatient coding as well as inpatient and outpatient billing! Understanding Hospital Coding and Billing offers a comprehensive look at the world of hospital/facility coding and billing in a worktext format. This learning solution will promote understanding of the entire facility process from patient intake through the entire billing process. Knowledge of the total process is imperative to successful comprehension of both coding and billing in the facility setting.

Table of Contents

Preface	xiii
The Flow of the Hospital Organization	xvii
Introduction	xvii
The Hospital Revenue Cycle	xviii
Physician (Physician's Order)	xix
Scheduling/Appointments	xix
Admit/Registration	xix
Appropriate Consents for Treatment, Release of Information and Insurance Verification	xx
Charge Capturing	xx
Procedure Coding	xx
Discharage	xxi
Diagnosis Coding	xxi
Billing	xxi
Re-Billing	xxi
Appeals	xxi
Patient Billing	xxii
Collections	xxii
Payment Posting	xxii
Understanding the Patient Billing Process	xxii
Services Provided in the Facility Setting	xxiv
Career Opportunities in the Hospital Setting	xxvi
Scheduling/Appointments	xxvi
Admit/Registration	xxvi
Coding	xxvii
Inpatient DRG Coder	xxvii
Outpatient APC Coder	xxvii
Diagnostic Coder	xxviii
Physician-Facility Coder	xxviii
Billing/Patient Business	xxix
Compliance/Administration	xxix
Training	xxx
Conclusion	xxx
SECTION I HOSPITAL CODING AND BILLING OVERVIEW	1	(134)
Hospital Coding Overview	3	(34)
Introduction	3	(1)
ICD-9-CM Diagnostic Coding Guidelines	4	(10)
Coding Conventions	5	(4)
Additional ICD-9-CM Diagnostic Coding Considerations	9	(1)
V Codes	9	(1)
E Codes	10	(1)
Table of Drugs and Chemicals	10	(1)
Hypertension Table	11	(1)
Neoplasms	11	(1)
Pregnancy Coding	11	(1)
Injuries/Trauma	12	(1)
Burns	12	(2)
ICD-9-CM Procedural Coding Guidelines	14	(6)
Additional Coding Considerations for ICD-9-CM Procedural Coding	18	(2)
CPT-4/HCPCS Procedure Coding Guidelines	20	(7)
CPT-4 Coding	20	(2)
Further CPT-4 Breakdown	22	(3)
Modifier Codes	25	(1)
HCPCS Coding	26	(1)
Review of Appropriate Coding Assignments	27	(3)
Documentation Review	30	(6)
Conclusion	36	(1)
Hospital Billing Process	37	(38)
General Overview of the Billing Process	38	(1)
Admission/Preadmission Process	38	(3)
Admission Forms	38	(1)
Consent Forms	38	(3)
Insurance Carriers	41	(6)
Medicare	42	(1)
Medicaid	42	(1)
Managed Care Plans	43	(1)
Health Maintenance Organizations (HMOs)	43	(1)
Preferred Provider Organizations (PPOs)	43	(1)
Exclusive Provider Organization (EPO)	44	(1)
Point of Service Organization (POS)	44	(1)
Commercial Insurance/Indemnity Insurance	44	(2)
CHAMPUS and CHAMPVA	46	(1)
Workers' Compensation	46	(1)
Medically Indigent	46	(1)
Capturing Patient Services	47	(18)
Chargemaster and Charge Ticket Forms	47	(1)
Chargemaster	47	(2)
Revenue Codes	49	(16)
Coding and Health Information Department	65	(1)
Billing Department	65	(3)
Collection and Payment Policies	68	(6)
Conclusion	74	(1)
UB-92 Overview	75	(60)
General Overview of the Hospital Billing Form	75	(3)
FL 1-11: Facility/Provider Information	78	(5)
FL 12-23: Patient Information	83	(5)
FL 24-31: Condition Codes	88	(4)
FL 32-38: Occurrence Codes/Dates	92	(4)
FL 39-41: Value Codes/Amounts	96	(4)
FL 42-49: Revenue Codes/Information	100	(26)
FL 50-66: Third Party Information (Payer, Insured, Employer)	126	(4)
FL 67-81: Diagnosis/Procedure Codes	130	(1)
FL 82-83: Attending Physician Information	131	(2)
FL 84-86: Remark Section	133	(1)
Conclusion	134	(1)
SECTION II INPATIENT CODING AND BILLING	135	(112)
Inpatient Coding	137	(42)
ICD-9-CM Diagnostic Coding Tools	137	(5)
Inpatient ICD-9-CM Diagnostic Coding	142	(5)
Additional ICD-9-CM Diagnostic Coding Guidelines	147	(7)
Admitting Diagnosis	148	(3)
Specific ICD-9-CM Inpatient Diagnostic Coding Rules	151	(1)
Acceptance Only as Principal Diagnosis	151	(1)
Acceptable Only as Subsequent Diagnosis Code(s)	152	(1)
Complications and Comorbidity Diagnosis	152	(1)
The Query Process	153	(1)
Special Inpatient ICD-9-CM Coding Considerations	154	(9)
Infectious and Parasitic Diseases	154	(1)
Bacteremia vs. Septicemia	154	(1)
Gram-Negative vs. Gram-Positive	155	(1)
HIV Infection Coding	155	(1)
Viral Infections	155	(1)
Neoplasms	156	(1)
Morphology Neoplasm Codes	156	(1)
Endocrine, Nutritional, Metabolic Diseases and Immunity Disorders	157	(1)
Diseases of Blood and Blood-Forming Organs	158	(1)
Mental Disorders	158	(1)
Central Nervous System	159	(1)
Disorders of the Eye and Ocular Adnexa	159	(1)
Diseases of Ear	159	(1)
Diseases of Circulatory System	160	(1)
Diseases of the Respiratory System	160	(1)
Diseases of the Digestive System	161	(1)
Diseases of Genitourinary System	162	(1)
Complications of Pregnancy, Childbirth and Puerperium	162	(1)
Diseases of Skin and Subcutaneous Tissue	162	(1)
Diseases of Musculoskeletal System and Connective Tissue	163	(1)
Congenital Anomalies and Conditions Arising From Perinatal Period	163	(1)
Injuries and Poisonings	163	(15)
ICD-9-CM Procedural Coding	164	(1)
ICD-9-CM Procedure Code Index	165	(1)
Specific Coding Guidelines for ICD-9-CM Procedural Coding	165	(1)
Incomplete Procedure	166	(1)
Nervous System	166	(1)
Endocrine System	166	(1)
Eye	166	(1)
Ear	166	(1)
Nose, Mouth, Pharynx	167	(1)
Respiratory System	167	(1)
Cardiovascular/Heart Assist System	167	(1)
Hemic and Lymphatic System	167	(1)
Digestive System	167	(1)
Urinary System	168	(1)
Male Genital Organs	168	(1)
Female Genital Organs	168	(1)
Obstetrics	168	(1)
Musculoskeletal System	168	(1)
Integumentary System	168	(1)
Miscellaneous	169	(9)
Conclusion	178	(1)
Inpatient Billing	179	(68)
Methodologies for Inpatient Services	179	(30)
Concepts of Prospective Payment System (PPS)	180	(1)
Diagnosis Related Groups	181	(21)
Special DRG Assignments	202	(7)
Conclusion	209	(38)
SECTION III OUTPATIENT CODING/BILLING	247	(130)
Outpatient Coding	249	(66)
Introduction	250	(1)
Documentation Review for Key Elements	250	(1)
General ICD-9-CM Diagnostic Coding Guidelines	250	(5)
ICD-9-CM Code Index	252	(1)
Specific Outpatient ICD-9-CM Coding Considerations	252	(1)
HIV/AIDS Infection	252	(1)
Diabetes/Complications and Manifestations	253	(1)
Mental Disorders	253	(1)
Postoperative Complication	253	(1)
Pneumonia	253	(1)
Hypertension	253	(1)
Contraceptive Management	254	(1)
Late Effect Codes	254	(1)
Neoplasm Codes	254	(1)
ICD-9-CM Procedure Coding	255	(1)
General Procedure Coding Guidelines (CPT-4/HCPCS)	256	(7)
CPT-4 General Coding Guidelines	259	(1)
Modifier Codes	260	(3)
CPT-4 Specific Section Guidelines	263	(5)
Outpatient Evaluation and Management CPT-4 Coding Considerations	264	(4)
Anesthesia Coding Guidelines	268	(1)
Outpatient CPT-4 Surgery Coding Guidelines	268	(3)
General Surgery Definitions	268	(1)
General Surgical Guidelines	269	(2)
CPT-4 Surgical Modifier Codes	271	(24)
Specific Integumentary System Services Guidelines (10000-19999)	274	(1)
Removal Lesions	274	(1)
Lacerations/Wound Repairs	275	(1)
Skin Grafts	275	(1)
Breast Procedures	276	(1)
Specific Musculoskeletal System Services Guidelines (20000-29999)	276	(1)
Fracture/Dislocation Repair Codes	276	(1)
Cast/Splint Application Codes	277	(1)
Arthroscopic Procedures	277	(1)
Specific Respiratory System Services Guidelines (30000-32999)	278	(1)
Specific Cardiovascular System Services Guidelines (33010-37799)	278	(1)
Pacemakers/Defibrillators	278	(1)
Grafting for Coronary Artery Bypass Grafts	279	(1)
Ventricle Assist Device Insertions (Codes 33975-33980)	279	(1)
Repair of Aneurysms	279	(1)
Vascular Injection Procedures	280	(1)
Central Venous Catheters	280	(1)
Specific Hemic and Lymphatic System Services Guidelines (38100-38999)	281	(1)
Lymph Nodes Excision	281	(1)
Specific Digestive System Guidelines (40490-49999)	281	(2)
Specific Urinary System Guidelines (50010-53899)	283	(1)
Specific Male Genital System Guidelines (54000-55899)	284	(1)
Specific Female Genital System Guidelines (56405-58999)	284	(1)
Specific Maternity Care and Delivery Guidelines (59000-59899)	284	(1)
Specific Endocrine System Services Guidelines (60000-60699)	285	(1)
Specific Nervous System Services Guidelines (61000-64999)	285	(1)
Specific Eye and Ocular Adnexa Services Guidelines (65091-68899)	286	(1)
Specific Auditory System Services Guidelines (69000-69979)	287	(1)
Operating Microscope Guidelines (69990)	287	(8)
Outpatient Radiology Coding Guidelines (CPT-4 Codes 70000-79999)	295	(17)
Specific Radiology Coding Guidelines	295	(6)
Outpatient Pathology Coding (CPT-4 Codes 80000-89999)	301	(1)
Specific Pathology Coding Guidelines	302	(1)
Outpatient Medicine Service Coding Guidelines (CPT-4 Codes 90281-99602)	303	(1)
Specific Medicine Coding Guidelines	303	(9)
HCPCS Codes	312	(2)
Specific HCPCS Coding Guidelines	313	(1)
Conclusion	314	(1)
Outpatient Billing	315	(62)
General Concepts of Outpatient Payment Prospective System (OPPS)	315	(19)
Ambulatory Payment Classifications (APCs)	316	(1)
Guidelines for Assigning APCs	316	(6)
Payment Status Indicators Paid Under APC Reimbursement Methodology	322	(1)
Payment Status Indicator S---Significant Procedures	322	(1)
Payment Status Indicator T---Surgical Services	323	(1)
Payment Status Indicator V---Medical Visits	323	(1)
Payment Status Indicator X---Ancillary Services	324	(1)
Reimbursable Payment Status Indicators Not Payable Under APC Methodology	324	(1)
Existing Drugs and Medical Devices	324	(1)
New Drug and Medical Devices	324	(1)
Partial Hospitalization	325	(1)
Outpatient Revenue Codes	326	(6)
Outpatient Code Editor	332	(2)
The Outpatient Billing Process	334	(4)
Other Outpatient Billing Considerations	338	(39)
Advance Beneficiary Notice	338	(1)
UB-92 Completion Guidelines	338	(8)
Conclusion	346	(31)
GLOSSARY	377	(8)
APPENDIX CASE SCENARIOS	385	(122)
Inpatient Cases	385	(80)
Outpatient Cases	465	(34)
Proposed UB 92 Revision (UB-04) Information	499	(8)
Index	507