Understanding Health Insurance A Guide to Professional Billing

ISBN-10: 1401837913
ISBN-13: 9781401837914
Edition: 7th 2004 (Revised)
List price: $211.95
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Description: Understanding Health Insurance: A Guide to Professional Billing, 7th edition, is a comprehensive guide for those learning about health insurance claims processing and reimbursement issues. The text utilizes a step-by-step approach to successful  More...

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Book details

List price: $211.95
Edition: 7th
Copyright year: 2004
Publisher: Delmar Cengage Learning
Publication date: 7/16/2003
Binding: Paperback
Pages: 656
Size: 8.25" wide x 10.75" long x 1.25" tall
Weight: 3.146
Language: English

Understanding Health Insurance: A Guide to Professional Billing, 7th edition, is a comprehensive guide for those learning about health insurance claims processing and reimbursement issues. The text utilizes a step-by-step approach to successful completion of health insurance claims. The objectives of this edition are to 1) introduce information about major third party payers, 2) provide up-to-date information about federal health care regulations, 3) clarify coding guidelines and provide application exercises for each coding system, 4) introduce reimbursement issues, 5) emphasize the importance of coding for medical necessity, and 6) help users develop the skill to complete claims accurately. Numerous examples help clarify key concepts. Case studies and review exercises provide users with numerous opportunities to apply knowledge and develop skills in completing CMS-1500 claims accurately. The textbook CD-ROM and accompanying workbook provide additional exercises and practice in completing CMS-1500 claims electronically. Current information is provided on CPT-5 and ICD-10-CM coding systems. The appendices include information about processing UB-92 (CMS-1450) claims and dental claims.

Founder and Former Chairperson, Medical Assisting Department Anne Arundel Community College, Arnold, MD

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

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