Understanding Health Insurance : A Guide to Professional Billing,9781401837914

Understanding Health Insurance : A Guide to Professional Billing

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Edition: 7th
ISBN13: 9781401837914
ISBN10: 1401837913
Format: Paperback
Pub. Date: 2003-07-16
Publisher(s): Cengage Learning
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Summary

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.

Table of Contents

List of Tables viii
Preface ix
Chapter 1 Health Insurance Specialist-Roles and Responsibilities 1(14)
Health Insurance Overview
12(2)
Basic Skill Requirements
14(4)
Health Insurance Specialist Responsibilities
18(1)
Professional Credentials
19
Chapter 2 Introduction to Health Insurance 15(16)
What is Health Insurance?
16(1)
Disability and Liability Insurance
16(2)
Major Developments in Health insurance
18(7)
Health Insurance Coverage Statistics
25(6)
Chapter 3 Managed Health Care 31(20)
History of Managed Health Care
32(2)
Managed Care Organizations
34(5)
Six Managed Care Models
39(4)
Accreditation of Managed Care Organizations
43(1)
Effects of Managed Care on a Physician's Practice
43(8)
Chapter 4 Life Cycle of an Insurance Claim 51(30)
Development of the Claim
52(1)
New Patient Interview and Check-In Procedure
52(9)
Established Patient Return Visit
61(1)
Postclinical Check-Out Procedures
62(5)
Insurance Company Processing of a Claim
67(3)
Maintaining Insurance Claim Files
70(5)
Delinquent Claims
75(6)
Chapter 5 Legal and Regulatory Considerations 81(36)
Introduction to Legal and Regulatory Considerations
82(4)
Confidentiality of Patient Information
86(6)
Claims Information Telephone Inquiries
92(1)
Facsimile Transmission
93(1)
Confidentiality and the Internet
94(1)
Retention of Patient Information and Health Insurance Records
94(1)
Employee Retirement Income Security Act (ERISA)
94(1)
Medical Necessity
95(1)
Federal False Claims Act
95(1)
Health Insurance Portability and Accountability Act of 1996
96(21)
Chapter 6 ICD-9-CM Coding 117(66)
Introduction to ICD-9-CM
118(1)
Outpatient Coding Guidelines
119(3)
Primary and Principal Diagnoses
122(2)
Principal versus Secondary Procedures
124(1)
Coding Qualified Diagnoses
125(1)
ICD-9-CM Coding System
126(4)
ICD-9-CM Index to Diseases
130(2)
Basic Steps for Using the Index to Diseases
132(4)
ICD-9-CM Tabular List of Diseases
136(7)
Index to Procedures and Tabular List of Procedures
143(1)
ICD-9-CM Index to Diseases Tables
144(11)
Supplementary Classifications
155(4)
Coding Special Disorders
159(4)
Considerations to Ensure Accurate ICD-9-CM Coding
163(1)
ICD-10-CM: Diagnostic Coding for the Future
164(19)
Chapter 7 CPT Coding 183(68)
CPT Coding System
184(5)
CPT Categories, Subcategories, and Headings
189(4)
CPT Index
193(3)
CPT Modifiers
196(11)
Basic Steps for Coding Procedures and Services
207(1)
Surgery Section
208(5)
Coding Special Surgery Cases
213(4)
Medicine Section
217(1)
Radiology Section
218(2)
Pathology/Laboratory Section
220(4)
Evaluation and Management Section
224(11)
Evaluation and Management Categories
235(16)
Chapter 8 HCPCS Coding System 251(20)
HCPCS Coding System
252(1)
HCPCS Level 11 Codes
253(12)
Determining Carrier Responsibility
265(1)
Assigning HCPCS Level II Codes
266(5)
Chapter 9 CMS Reimbursement Issues 271(10)
Historical Perspective of CMS Reimbursement Systems
272(1)
CMS Payment Systems
272(1)
Ambulance Fee Schedule
273(1)
Ambulatory Surgical Centers (ASC)
274(1)
Clinical Lab Diagnostic Fee Schedule
275(1)
Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule
275(1)
Home Health Prospective Payment System
275(1)
Hospital Inpatient Prospective Payment System
276(1)
Inpatient Rehabilitation Facility Prospective Payment System
277(1)
Long-Term Care Hospitals Prospective Payment System
277(1)
Skilled Nursing Facility (SNF) Prospective Payment System
278(1)
Medicare Physician Fee Schedule
278(1)
Anesthesia, Pathology/Laboratory, and Radiology Services
278(3)
Chapter 10 Coding for Medical Necessity 281(30)
Applying Coding Guidelines
288(5)
CPTIHCPCS Billing Considerations
293(1)
Coding from Case Scenarios
293(4)
Coding from Clinic Notes and Diagnostic Test Results
297(5)
Coding Operative Reports
302(9)
Chapter 11 Essential CMS-1500 Claim Instructions 311(28)
General Billing Guidelines
318(3)
Optical Scanning Guidelines
321(3)
Assignment of Benefits/Accept Assignment
324(1)
Reporting Diagnoses: ICD-9-CM Codes
324(1)
Reporting Procedures and Services: HCPCS
325(5)
National Standard Employer Identifier Number
330(1)
Reporting the Billing Entity
331(1)
Processing Secondary Claims
331(2)
Common Errors That Delay Processing
333(1)
Final Steps in Processing Paper Claims
333(1)
Maintaining insurance Claim Files for the Practice
334(5)
Chapter 12 Filing Commercial Claims 339(26)
Commercial Claims
340(1)
Step-by-Step Claim Instructions-Blocks 1-13 Entering Patient and Policy Information
341(7)
Step-by-Step Claim Instructions-Blocks 14-23 Dates of Service and Diagnosis Codes
348(2)
Step-by-Step Claim Instructions-Block 24 Procedures, Services, and Supplies
350(4)
Step-by-Step Claim Instructions-Blocks 25-33 Provider Information
354(3)
Commercial Secondary Coverage
357(1)
Modifications to Primary CMS-1500 Claims
357(1)
Modifications to Secondary CMS-1500 Claims
358(7)
Chapter 13 Blue Cross and Blue Shield Plans 365(36)
History of Blue Cross and Blue Shield
366(4)
Blue Cross Blue Shield Plans
370(6)
Billing Information Summary
376(1)
Step-by-Step Claim Instructions
377(13)
BCES Secondary Coverage
390(11)
Chapter 14 Medicare 401(64)
Medicare Eligibility
402(1)
Medicare Enrollment
403(2)
Medicare Part A Coverage
405(3)
Medicare Part B Coverage
408(2)
Participating Providers
410(1)
Nonparticipating Providers
411(4)
Private Contracting
415(1)
Advance Beneficiary Notice
416(1)
Medicare as a Secondary Payer
417(4)
Medicare Plans
421(10)
Billing Notes
431(1)
Step-by-Step Claim Instructions
432(16)
Medicare with Medigap Claims
448(4)
Medicare-Medicaid Crossover Claims
452(1)
Medicare Secondary Payer (MSP) Claims
452(3)
Roster Billing for Mass Vaccination Programs
455(10)
Chapter 15 Medicaid 465(34)
Federal Eligibility Requirements for Medicaid
466(3)
Medicaid Covered Services
469(4)
Medicare-Medicaid Relationship
473(1)
Medicaid as a Secondary Payer
474(1)
Participating Providers
474(1)
Medicaid and Managed Care
474(1)
Medicaid Eligibility Verification System (MEVS)
474(1)
Medicaid Remittance Advice
475(1)
Utilization Review
476(1)
Fraud and Abuse
476(1)
Medial Necessity
476(1)
Billing Information Notes
476(2)
Step-by-Step Claim Instructions
478(11)
Medicaid as Secondary Claims
489(4)
Mother/Baby Claims
493(6)
Chapter 16 Tricare 499(34)
Tricare Background
500(1)
Tricare Administration
500(3)
CHAMPVA
503(1)
Tricare Options
504(4)
Tricare Programs and Demonstration Projects
508(2)
Tricare Supplemental Plans
510(1)
Tricare Billing Information
510(3)
Tricare Primary Claim Instructions
513(13)
Primary Tricare with a Supplemental Policy
526(1)
Tricare as Secondary Payer
526(7)
Chapter 17 Workers' Compensation 533(30)
Federal Workers' Compensation Programs
534(2)
State Workers' Compensation Program
536(1)
Eligibility for Coverage
537(1)
Classification of Workers' Compensation Cases
537(2)
Special Handling of Workers' Compensation Cases
539(1)
Workers' Compensation and Managed Care
539(1)
First Report of Injury
540(3)
Progress Reports
543(2)
Appeals and Adjudication
545(1)
Fraud and Abuse
545(1)
Billing Information Notes
545(2)
Workers' Compensation Claim Instructions-Patient and Policy Identification
547(16)
Appendices
Appendix I
Case Studies: Set One
563(22)
Appendix II
Case Studies: Set Two
585(47)
Appendix III
Forms
632(1)
CMS-1500 Claim
633(1)
Coding Case Study Form
634(1)
Insurance Plan Comparison Chart
635(1)
E/M Codebuilder
636(3)
Appendix IV
Answers to Coding Exercises
639(1)
Answers to ICD-9-CM Coding Exercises (Chapter 6)
639(2)
Answers to CPT Coding Exercises (Chapter 7)
641(4)
Answers to Chapter 8 Exercises
645(1)
Answers to Chapter 10 Exercises
645
Appendix V
Using the Student Practice CD-ROM
641(9)
License Agreement for Delmar Learning
650(1)
Appendix VI
UB-92
651(6)
Bibliography 657(2)
Glossary 659(18)
Index 677

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