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| List of Tables | |
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| Preface | |
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| Health Insurance Specialist--Roles and Responsibilities | |
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| Health Insurance Overview | |
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| Basic Skill Requirements | |
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| Health Insurance Specialist Responsibilities | |
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| Professional Credentials | |
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| Introduction to Health Insurance | |
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| What is Health Insurance? | |
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| Disability and Liability Insurance | |
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| Major Developments in Health Insurance | |
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| Health Insurance Coverage Statistics | |
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| Managed Health Care | |
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| History of Managed Health Care | |
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| Managed Care Organizations | |
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| Six Managed Care Models | |
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| Accreditation of Managed Care Organizations | |
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| Effects of Managed Care on a Physician's Practice | |
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| Life Cycle of an Insurance Claim | |
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| Development of the Claim | |
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| New Patient Interview and Check-In Procedure | |
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| Established Patient Return Visit | |
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| Postclinical Check-Out Procedures | |
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| Insurance Company Processing of a Claim | |
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| Maintaining Insurance Claim Files | |
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| Delinquent Claims | |
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| Legal and Regulatory Considerations | |
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| Introduction to Legal and Regulatory Considerations | |
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| Confidentiality of Patient Information | |
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| Claims Information Telephone Inquiries | |
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| Facsimile Transmission | |
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| Confidentiality and the Internet | |
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| Retention of Patient Information and Health Insurance Records | |
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| Employee Retirement Income Security Act (ERISA) | |
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| Medical Necessity | |
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| Federal False Claims Act | |
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| Health Insurance Portability and Accountability Act of 1996 | |
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| ICD-9-CM Coding | |
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| Introduction to ICD-9-CM | |
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| Outpatient Coding Guidelines | |
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| Primary and Principal Diagnoses | |
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| Principal versus Secondary Procedures | |
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| Coding Qualified Diagnoses | |
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| ICD-9-CM Coding System | |
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| ICD-9-CM Index to Diseases | |
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| Basic Steps for Using the Index to Diseases | |
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| ICD-9-CM Tabular List of Diseases | |
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| Index to Procedures and Tabular List of Procedures | |
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| ICD-9-CM Index to Diseases Tables | |
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| Supplementary Classifications | |
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| Coding Special Disorders | |
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| Considerations to Ensure Accurate ICD-9-CM Coding | |
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| ICD-10-CM: Diagnostic Coding for the Future | |
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| CPT Coding | |
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| CPT Coding System | |
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| CPT Categories, Subcategories, and Headings | |
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| CPT Index | |
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| CPT Modifiers | |
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| Basic Steps for Coding Procedures and Services | |
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| Surgery Section | |
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| Coding Special Surgery Cases | |
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| Medicine Section | |
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| Radiology Section | |
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| Pathology/Laboratory Section | |
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| Evaluation and Management Section | |
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| Evaluation and Management Categories | |
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| HCPCS Coding System | |
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| HCPCS Coding System | |
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| HCPCS Level II Codes | |
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| Determining Carrier Responsibility | |
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| Assigning HCPCS Level II Codes | |
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| CMS Reimbursement Issues | |
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| Historical Perspective of CMS Reimbursement Systems | |
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| CMS Payment Systems | |
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| Ambulance Fee Schedule | |
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| Ambulatory Surgical Centers (ASC) | |
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| Clinical Lab Diagnostic Fee Schedule | |
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| Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule | |
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| Home Health Prospective Payment System | |
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| Hospital Inpatient Prospective Payment System | |
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| Inpatient Rehabilitation Facility Prospective Payment System | |
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| Long-Term Care Hospitals Prospective Payment System | |
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| Skilled Nursing Facility (SNF) Prospective Payment System | |
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| Medicare Physician Fee Schedule | |
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| Anesthesia, Pathology/Laboratory, and Radiology Services | |
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| Coding for Medical Necessity | |
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| Applying Coding Guidelines | |
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| CPT/HCPCS Billing Considerations | |
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| Coding from Case Scenarios | |
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| Coding from Clinic Notes and Diagnostic Test Results | |
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| Coding Operative Reports | |
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| Essential CMS-1500 Claim Instructions | |
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| General Billing Guidelines | |
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| Optical Scanning Guidelines | |
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| Assignment of Benefits/Accept Assignment | |
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| Reporting Diagnoses: ICD-9-CM Codes | |
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| Reporting Procedures and Services: HCPCS | |
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| National Standard Employer Identifier Number | |
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| Reporting the Billing Entity | |
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| Processing Secondary Claims | |
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| Common Errors That Delay Processing | |
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| Final Steps in Processing Paper Claims | |
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| Maintaining Insurance Claim Files for the Practice | |
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| Filing Commercial Claims | |
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| Commercial Claims | |
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| Step-by-Step Claim Instructions--Blocks 1-13 Entering Patient and Policy Information | |
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| Step-by-Step Claim Instructions--Blocks 14-23 Dates of Service and Diagnosis Codes | |
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| Step-by-Step Claim Instructions--Block 24--Procedures, Services, and Supplies | |
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| Step-by-Step Claim Instructions--Blocks 25-33 Provider Information | |
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| Commercial Secondary Coverage | |
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| Modifications to Primary CMS-1500 Claims | |
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| Modifications to Secondary CMS-1500 Claims | |
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| Blue Cross and Blue Shield Plans | |
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| History of Blue Cross and Blue Shield | |
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| Blue Cross Blue Shield Plans | |
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| Billing Information Summary | |
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| Step-by-Step Claim Instructions | |
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| BCBS Secondary Coverage | |
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| Medicare | |
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| Medicare Eligibility | |
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| Medicare Enrollment | |
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| Medicare Part A Coverage | |
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| Medicare Part B Coverage | |
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| Participating Providers | |
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| Nonparticipating Providers | |
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| Private Contracting | |
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| Advance Beneficiary Notice | |
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| Medicare as a Secondary Payer | |
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| Medicare Plans | |
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| Billing Notes | |
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| Step-by-Step Claim Instructions | |
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| Medicare with Medigap Claims | |
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| Medicare-Medicaid Crossover Claims | |
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| Medicare Secondary Payer (MSP) Claims | |
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| Roster Billing for Mass Vaccination Programs | |
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| Medicaid | |
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| Federal Eligibility Requirements for Medicaid | |
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| Medicaid Covered Services | |
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| Medicare-Medicaid Relationship | |
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| Medicaid as a Secondary Payer | |
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| Participating Providers | |
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| Medicaid and Managed Care | |
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| Medicaid Eligibility Verification System (MEVS) | |
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| Medicaid Remittance Advice | |
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| Utilization Review | |
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| Fraud and Abuse | |
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| Medical Necessity | |
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| Billing Information Notes | |
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| Step-by-Step Claim Instructions | |
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| Medicaid as Secondary Claims | |
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| Mother/Baby Claims | |
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| Tricare | |
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| Tricare Background | |
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| Tricare Administration | |
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| CHAMPVA | |
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| Tricare Options | |
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| Tricare Programs and Demonstration Projects | |
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| Tricare Supplemental Plans | |
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| Tricare Billing Information | |
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| Tricare Primary Claim Instructions | |
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| Primary Tricare with a Supplemental Policy | |
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| Tricare as Secondary Payer | |
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| Workers' Compensation | |
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| Federal Workers' Compensation Programs | |
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| State Workers' Compensation Program | |
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| Eligibility for Coverage | |
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| Classification of Workers' Compensation Cases | |
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| Special Handling of Workers' Compensation Cases | |
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| Workers' Compensation and Managed Care | |
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| First Report of Injury | |
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| Progress Reports | |
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| Appeals and Adjudication | |
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| Fraud and Abuse | |
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| Billing Information Notes | |
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| Workers' Compensation Claim Instructions--Patient and Policy Identification | |
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| Appendices | |
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| Case Studies: Set One | |
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| Case Studies: Set Two | |
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| Forms | |
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| CMS-1500 Claim | |
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| Coding Case Study Form | |
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| Insurance Plan Comparison Chart | |
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| E/M Codebuilder | |
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| Answers to Coding Exercises | |
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| Answers to ICD-9-CM Coding Exercises (Chapter 6) | |
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| Answers to CPT Coding Exercises (Chapter 7) | |
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| Answers to Chapter 8 Exercises | |
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| Answers to Chapter 10 Exercises | |
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| Using the Student Practice CD-ROM | |
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| License Agreement for Delmar Learning | |
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| UB-92 | |
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| Bibliography | |
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| Glossary | |
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| Index | |