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| Acknowledgments | |
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| Healthcare Providers | |
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| Introduction | |
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| Categorizing Healthcare Providers | |
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| Hospitals-Inpatient | |
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| Hospitals-Outpatient | |
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| Ambulatory Surgical Centers | |
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| Clinics, Physicians, and Practitioners | |
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| Home Health Services | |
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| Independent Diagnostic Testing Facilities | |
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| Comprehensive Outpatient Rehabilitation Facilities | |
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| Durable Medical Equipment Suppliers | |
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| Other Types of Healthcare Providers | |
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| Medicare Provider Types | |
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| Healthcare Provider Taxonomy | |
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| Summary and Conclusion | |
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| Types of Healthcare Payment Systems | |
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| Introduction | |
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| Third-Party Payer Concept | |
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| Cost-Based Payment Systems | |
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| Charge-Based Payment Systems | |
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| Fee Schedule Payment Systems | |
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| RBRVS (Resource-Based Relative Value System) | |
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| Prospective Payment Systems | |
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| Diagnosis-Related Groups (DRGs) | |
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| Ambulatory Payment Classifications (APCs) | |
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| Home Health Agency PPS and Skilled Nursing Facilities-Resource Utilization Groups | |
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| Special and Hybrid Payment Systems | |
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| Capitated Payment Systems | |
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| Payment System Interfaces | |
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| Managed Care and Payment Systems | |
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| Medicare Advantage | |
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| Other Managed Care Payment Systems | |
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| Summary and Conclusion | |
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| Healthcare Provider Organizational Structuring | |
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| Introduction | |
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| Business Structuring | |
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| Freestanding Healthcare Providers | |
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| Solo Physician Practice | |
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| Other Freestanding Healthcare Providers | |
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| Freestanding ASCs | |
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| Freestanding Hospitals | |
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| Provider-Based Facilities | |
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| Integrated Delivery Systems | |
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| Special Organizational Structuring | |
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| Summary and Conclusion | |
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| Revenue Cycle versus Reimbursement Cycle | |
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| Introduction | |
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| The Reimbursement Cycle | |
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| Optimizing the Reimbursement Cycle | |
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| Final Product | |
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| Key Features in the Reimbursement Cycle | |
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| Special Software Interfaces | |
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| Payment System Interfaces | |
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| Summary and Conclusion | |
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| Claims Generation and Adjudication | |
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| Introduction | |
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| Three Levels of Formality for Claim Filing | |
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| Medicare Conditions for Payment | |
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| Gaining Medicare Billing Privileges | |
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| Gaining Billing Privileges with Private TPPs | |
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| Preparing and Filing Claims | |
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| Claim Adjudication | |
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| Payment and Claims Reconciliation | |
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| Summary and Conclusion | |
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| HIPAA Administrative Simplification | |
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| Introduction | |
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| HIPAA Privacy | |
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| HIPAA TSC Rule | |
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| Standard Code Sets | |
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| Current Procedural Terminology-CPT* | |
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| Healthcare Common Procedure Coding System-HCPCS | |
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| International Classification of Diseases-ICD-9-CM | |
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| Revenue Codes for the UB-04 | |
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| Condition Codes for the UB-04 | |
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| Place of Service Codes for the 1500 | |
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| Standard Transaction Formats | |
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| National Provider Identifiers-NPIs | |
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| HIPAA Security | |
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| Summary and Conclusion | |
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| Compliance | |
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| Introduction | |
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| Coding, Billing, and Reimbursement Compliance-Overarching Issues | |
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| Medical Necessity | |
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| Claims Filing versus Claims Payment | |
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| Supporting Documentation | |
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| Statutory Compliance | |
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| Rules, Laws, and Information | |
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| Office of the Inspector General | |
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| Major Medicare Rules and Requirements | |
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| Recovery Audit Contractor Audits | |
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| Contractual Compliance | |
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| Beyond Statutory and Contractual Compliance | |
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| Establishing a Coding, Billing, and Reimbursement Compliance Program | |
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| Written Policies and Procedures | |
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| Employee Training | |
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| Monitoring and Auditing | |
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| Summary and Conclusion | |
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| Research, Problem Solving, and Knowledge-Base Development | |
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| Introduction | |
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| Systematic Process for Knowledge Management | |
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| Acquiring Information | |
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| Organizing Information | |
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| Analyzing and Assessing Information | |
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| Using the Information | |
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| Constant Change | |
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| Systematic Process for Problem Solving | |
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| Policies and Procedures | |
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| Summary and Conclusion | |
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| Case Study Listing | |
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| Chapter 1 | |
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| Chapter 2 | |
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| Chapter 3 | |
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| Chapter 4 | |
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| Chapter 5 | |
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| Chapter 6 | |
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| Chapter 7 | |
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| Chapter 8 | |
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| Acronym Listing | |
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| Index | |
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| Author | |