Table Of Contents:
SECTION I Career and Professionalism

A Career as an Insurance Billing Specialist 3(28)

Role and Responsibilities of the Insurance Billing Specialist 4(10)

Job Titles 4(1)

Job Responsibilities 5(1)

Educational and Training Requirements 6(2)

Personal and Professional Qualifications 8(3)

Medical Etiquette 11(1)

Medical Ethics 11(3)

Confidential Communication 14(4)

Nonprivileged Information 14(1)

Privileged Information 14(4)

Professional Liability 18(4)

Employer Liability 18(1)

Employee Liability 19(1)

Fraud 19(1)

Abuse 19(1)

Compliance Program 19(1)

Embezzlement 19(3)

Summation and Preview 22(1)

Review and Practice 23(4)

CPR Session: Answers 27(1)

Resources 27(4)
SECTION II Basics of Health Insurance

Fundamentals of Health Insurance Coverage 31(22)

Health Insurance Contracts 32(1)

Group Contract 32(1)

Individual Contract 33(1)

Prepaid Health Plan 33(1)

Legal Principles of Insurance 33(5)

The Insurance Policy 34(1)

Policy Terms and Financial Obligation 35(3)

Insurance Coverage and Benefits 38(1)

Physician/Patient Contract 39(5)

Private Patients 39(1)

Managed Care Patients 40(1)

Assignment of Medical Benefits 40(1)

Patients Examined for Employment or Disability 41(1)

Workers' Compensation Patients 41(1)

Termination of Physician/Patient Contract 41(3)

Types of Health Insurance Programs 44(1)

Government Plans 44(1)

Managed Care Contracts 44(1)

Commercial Carriers 45(1)

Industrial Insurance 45(1)

Income Continuation Benefits 45(1)

Summation and Preview 45(2)

Review and Practice 47(4)

CPR Session: Answers 51(1)

Resources 51(2)

Source Documents and the Insurance Claim Cycle 53(20)

The Reimbursement Cycle 54(1)

Patient Education 54(1)

Source Documents 54(12)

Patient Registration Form 54(4)

Insurance Identification Card 58(3)

Encounter Form 61(1)

Patient Account/Ledger 62(1)

Day Sheet/Daily Log 63(1)

The Insurance Claim Form 64(1)

Insurance Payment Check and Explanation of Benefits/Remittance Advice Document 65(1)

Patient Statement 66(1)

Summation and Preview 66(1)

Review and Practice 67(4)

CPR Session: Answers 71(1)

Resources 71(2)
SECTION III Coding Insurance Claims

Coding Diagnosis 73(34)

The Diagnostic Coding System 74(1)

Diagnosis-Related Procedures 74(1)

International Classification of Diseases, 9th Revision, Clinical Modification 75(1)

Organization and Format 75(1)

Contents 75(1)

Using the Diagnostic Codebook 76(13)

Abbreviations, Punctuation, and Symbols 76(1)

Other Conventions 76(1)

Instrumental Notations 76(2)

Coding Vocabulary and Instructions 78(5)

The Coding Process 83(6)

Basic Steps in Coding 89(6)

Tables 90(1)

Hypertension Table 90(5)

Coding Special Conditions 95(1)

Supplementary Classifications 95(1)

V Codes 95(1)

E Codes 95(1)

ICD-10-CM Diagnostic and Procedure Codes 96(1)

Summation and Preview 97(2)

Review and Practice 99(4)

CPR Session: Answers 103(1)

Resource 104(3)

Coding Procedures Part I: Introduction and Evaluation and Management Services 107(26)

The Importance of Procedure Coding 108(1)

The Standard Code Set 108(4)

Level I Codes-Current Procedural Terminology (CPT) 109(2)

Level II-National HCPCS Codes 111(1)

National Drug Codes 111(1)

Level III-Regional or Local HCPCS Codes 111(1)

Introduction to the CPT Codebook 112(1)

Category I, II, and III Codes 112(1)

Coding Evaluation and Management Services 113(10)

Evaluation and Management Section 113(9)

Adjunct Codes 122(1)

Summation and Preview 123(2)

Review and Practice 125(6)

CPR Session: Answers 131(1)

Resources 131(2)

Coding Procedures Part II: Anesthesia, Surgery, Radiology, Pathology/Laboratory, and Medicine 133(38)

Coding Procedures and Services 134(21)

Anesthesia Section 134(3)

Introduction to the Surgery Section 137(7)

Surgery Section 144(8)

Radiology Section 152(1)

Pathology and Laboratory Section 153(1)

Medicine Section 153(2)

Coding Terminology 155(3)

Bundled Code 155(1)

Unbundling 155(1)

Downcoding 156(1)

Upcoding 156(1)

Code Edits 157(1)

Illegal or Unethical Coding 158(1)

Modifiers 158(1)

Summation and Preview 159(4)

Chapter 6 Review and Practice 163(4)

CPR Session: Answers 167(1)

Resources 168(3)
SECTION IV Claim Submission

Documentation and the Medical Record 171(30)

The Medical Record 172(2)

Abstracting Information from a Medical Record 172(2)

The Documentation Process 174(3)

Subjective Information 174(1)

Objective Findings 174(1)

SOAP Chart Notes 174(1)

Record Systems 175(1)

Documenters 176(1)

Reasons for Documentation 177(1)

General Principles of Medical Record Documentation 177(2)

Medical Necessity 177(1)

Documentation Guidelines 177(2)

Components of a Medical Record 179(3)

Contents of a Medical Report 179(3)

Legalities of a Medical Record 182(5)

Faxing Documents 183(2)

Faxing Legal Documents 185(1)

Subpoena 185(1)

Prevention of Legal Problems 185(2)

Data Storage 187(2)

Medical Record Retention 187(1)

Financial Document Retention 187(1)

Destruction of Medical Records 187(2)

Auditing a Medical Record 189(1)

Internal Reviews 189(1)

External Audit 189(1)

Compliance 190(1)

Summation and Preview 190(3)

Review and Practice 193(4)

CPR Session: Answers 197(1)

Resources 198(3)

The Health Insurance Claim Form: Completion and Submission 201(32)

The Insurance Billing Process 202(1)

Submission Time-Limit Requirements 202(1)

The Health Insurance Claim Form 203(2)

Types of Claims 203(1)

Optical Character Recognition 204(1)

Claim Payment Turnaround Time 204(1)

Claim Status 204(1)

Completion of Insurance Claim Forms 205(1)

Individual Insurance Forms 205(1)

Group Insurance Forms 205(1)

Secondary Insurance Submission 205(1)

Claim Form Requirements 206(9)

Divisions of the Claim Form 206(1)

Block-by-Block Instructions and Insurance Templates 207(1)

Insurance Company Name and Address 208(2)

Diagnosis 210(1)

Service Dates 210(1)

Place of Service and Type of Service 210(1)

No Charge 211(1)

Physicians' Identification Numbers 212(2)

Physician's Signature 214(1)

Insurance Biller's Initials 214(1)

Proofreading Claims 214(1)

Supporting Documentation 215(1)

Computers in the Medical Office 215(5)

Electronic Data Interchange 215(2)

Electronic Claims Processor 217(1)

Advantage of Electronic Claim Submission 218(1)

Medical Software Programs 218(1)

Networks 219(1)

Summation and Preview 220(1)

Review and Practice 221(8)

CPR Session: Answers 229(2)

Resources 231(2)

Fees: Private Insurance and Managed Care 233(42)

Private Insurance Versus Managed Care Plans 234(1)

Participating Provider 234(1)

Nonparticipating Provider 234(1)

Private Insurance 235(9)

Fee-for-Service 236(1)

Fee Schedule 236(5)

Communicating Fees 241(3)

Managed Care 244(10)

Future of Managed Care 245(1)

Financial Management 245(2)

Types of Managed Care Organizations 247(2)

Medical Review 249(1)

Management of Plan 250(2)

Plan Administration 252(2)

Summation and Preview 254(1)

Review and Practice 255(16)

CPR Session: Answers 271(1)

Resources 272(3)
SECTION V Insurance Programs

The Medicaid Program 275(22)

The Birth of Medicaid 276(1)

Medicaid Administration 276(1)

Accepting Medicaid Patients 276(1)

Medicaid Eligibility 277(5)

Categorically Needy 277(1)

Medically Needy 278(1)

Identification Card 278(1)

Verifying Eligibility 279(1)

Copayment Requirements 279(1)

Prior Approval 279(3)

Retroactive Eligibility 282(1)

Medicaid Assistance Programs and Benefits 282(3)

Early and Periodic Screening, Diagnosis, and Treatment 282(1)

Maternal and Child Health Programs 282(1)

Low-Income Medicare Recipients 283(1)

Disallowed Services 283(2)

Medicaid Managed Care 285(1)

Claim Procedures 285(2)

Reporting the Share of Cost 285(1)

Reporting Prior Approval 285(1)

Time Limit 285(1)

Reciprocity 285(1)

Claim Form 286(1)

Medicaid Fraud Control 287(1)

Summation and Preview 288(1)

Review and Practice 289(6)

CPR Session: Answers 295(1)

Resources 295(2)

The Medicare Program 297(50)

Medicare Policies and Regulations 298(9)

Eligibility Requirements 298(1)

Medicare Enrollment 298(2)

Identification Card 300(1)

Coverage and Benefits 301(6)

Medicare and Additional Insurance Programs 307(4)

Medicare and Medicaid 307(1)

Medicare and Medigap 307(1)

Medicare Secondary Payer (MSP) 308(3)

Medicare Fraud and Abuse Protection 311(2)

Peer Review Organizations 311(1)

Federal False Claims Amendment Act 311(1)

Health Insurance Portability and Accountability Act 311(1)

Civil Monetary Penalties Law 311(1)

Stark I and II Regulations 312(1)

Clinical Laboratory Improvement Amendment 312(1)

Payment Fundamentals 313(6)

Medicare Fee Schedule 313(1)

Participating Physician 313(1)

Nonparticipating Physician 314(1)

New Patient Versus Established Patient 314(1)

Prepayment Screens 315(1)

Correct Coding Initiative 315(1)

Denied Services 315(1)

Elective Surgery Estimates 315(2)

Hospital Reimbursement 317(2)

Health Care Financing Administration Common Procedure Coding System (HCPCS) 319(1)

Coding Regulations 319(1)

Medicare Claim Submission 320(5)

Fiscal Intermediaries and Fiscal Agents 320(1)

Provider Identification Numbers 320(1)

Patient Signature Authorization 320(1)

Physician's Signature Requirement 321(1)

Time Limit 321(1)

Manual Claim Submission 322(1)

Electronic Claim Submission 322(1)

Medicare/Medicaid Claim Submission 322(1)

Medicare/Medigap Claim Submission 323(1)

MSP Claim Submission 324(1)

Deceased Patient Claim Submission 324(1)

Physician Substitute Claim Submission 325(1)

Summation and Preview 325(2)

Review and Practice 327(16)

CPR Session: Answers 343(1)

Resources 344(3)

The TRICARE and CHAMPVA Programs 347(42)

Understanding TRICARE Programs 348(2)

Eligibility 348(1)

Nonavailability Statement 349(1)

Fiscal Year 349(1)

TRICARE Standard 350(8)

Enrollment 350(1)

Identification Card 350(1)

Benefits 350(1)

Treatment Facilities 350(1)

Authorized Providers of Healthcare 351(1)

Referral and Preauthorization 351(3)

Payment 354(4)

TRICARE Extra 358(2)

Enrollment 358(1)

Identification Card 358(1)

Benefits 358(1)

Network Providers 359(1)

Referral and Preauthorization 359(1)

Payment 359(1)

TRICARE Prime 360(3)

Enrollment 360(1)

Primary Care Manager 360(1)

Identification Card 360(1)

Benefit 360(1)

Referral and Preauthorization 361(1)

Payments 361(1)

Point-of Service Option 362(1)

TRICARE for Life 362(1)

TRICARE Plus 362(1)

TRICARE Prime Remote Program 363(1)

Enrollment 363(1)

Identification Card 363(1)

Benefits 363(1)

Referral and Preauthorization 363(1)

Payment 364(1)

Supplemental Health Care Program 364(1)

Enrollment 364(1)

Identification Card 364(1)

Benefits 364(1)

Referral and Preauthorization 364(1)

Payment 364(1)

Other TRICARE Health Benefits 364(1)

CHAMPVA Program 364(3)

Eligibility 365(1)

Enrollment 365(1)

Identification Card 366(1)

Benefits 366(1)

Provider 367(1)

Referral and Preauthorization 367(1)

Payment 367(1)

Medical Records 367(1)

Medical Record Access 367(1)

Release of Patient Information 367(1)

Release of Medical Records 367(1)

Claim Procedures 368(2)

Claim Processing Areas 368(1)

Claim Form Requirements 368(1)

Electronic Claim Submission 369(1)

TRICARE Standard and CHAMPVA Claims 370(1)

TRICARE Extra and TRICARE Prime Claims 370(1)

TRICARE Prime Remote and Supplemental Health Care Program Claims 370(1)

TRICARE/CHAMPVA and Other Insurance Coverage 370(2)

HMO Coverage and TRICARE 371(1)

Medicaid and TRICARE/CHAMPVA 371(1)

Medicare and TRICARE 371(1)

Medicare and CHAMPVA 371(1)

Third Party Liabilities and TRICARE/CHAMPVA 371(1)

Workers' Compensation and TRICARE/CHAMPVA 372(1)

Summation and Preview 372(1)

Review and Practice 373(12)

CPR Session: Answers 385(1)

Resources 385(4)

Workers' Compensation Coverage and Other Disability Programs 389(42)

Origins of Workers' Compensation 390(1)

Workers' Compensation Reform 390(1)

Workers' Compensation Managed Care 390(1)

Workers' Compensation Statutes 390(2)

Federal Laws 391(1)

State Laws 391(1)

Compulsory and Elective Laws 391(1)

Interstate Laws 391(1)

Provisions of Workers' Compensation Laws 391(1)

Employers' Liability Insurance 391(1)

Funding Workers' Compensation 392(1)

Second Injury Fund 392(1)

Workers' Compensation Requirements 392(4)

Eligibility 392(1)

Referring the Injured or III Worker 393(1)

Selecting a Treating Physician 394(1)

Waiting Period 394(1)

Medical Evaluator 394(1)

Benefits 395(1)

Types of Workers' Compensation Claims 396(1)

Nondisability Claim 396(1)

Temporary Disability Claim 396(1)

Permanent Disability Claim 397(1)

Common Workers' Compensation Terminology 397(2)

Insurance Adjuster 397(1)

Case Manager 397(1)

Permanent and Stationary 397(1)

Compromise and Release 397(1)

Rating 397(1)

Surveillance 398(1)

Employee's Claim for Workers' Compensation Benefits 399(1)

Fraud and Abuse 399(1)

Payment of Benefits 400(1)

Medical Reports 400(7)

Confidentiality 400(1)

Documentation 400(1)

Medical Record Keeping 400(1)

Appointments 400(1)

Reporting Requirements 400(6)

Electronic Reports 406(1)

Testing and Treatment 407(1)

Vocational Rehabilitation 407(1)

Physical Therapy 407(1)

Ergonomics 407(1)

Legal Situations 407(3)

Depositions 407(1)

Medical Testimony 407(1)

Liens 408(1)

Third Party Subrogation 409(1)

Claim Procedures 410(3)

Financial Responsibility 410(1)

Fee Schedules 410(1)

Helpful Billing Tips 410(2)

Claim Submission 412(1)

Occupational Safety and Health Administration (OSHA) 413(1)

Background 413(1)

Coverage 413(1)

Regulations 413(1)

Filling a Complaint 413(1)

Record Keeping and Reporting 413(1)

Other Disability Insurance Plans 414(3)

Disability Income Insurance 414(1)

Federal Disability Programs 415(1)

State Disability Insurance 416(1)

Voluntary Disability Insurance 417(1)

Summation and Preview 417(2)

Review and Practice 419(8)

CPR Session: Answers 427(1)

Resources 428(3)
SECTION VI Receiving Payment and Problem Solving

Patient Billing: Credit and Collection Practices 431(28)

Patient Payment Responsibility 432(1)

Itemized Statements 432(7)

Age Analysis 432(3)

Dun Messages 435(1)

Manual Billing 435(1)

Computer Billing 435(1)

Billing Services 435(2)

Billing Procedures 437(2)

Credit Arrangements 439(3)

Payment Options 439(3)

The Collection Process 442(8)

Office Collection Techniques 442(3)

Other Collection Options 445(2)

Credit and Collection Laws 447(2)

Office Collection Problem Solving 449(1)

Summation and Preview 450(1)

Review and Practice 451(4)

CPR Session: Answers 455(1)

Resources 456(3)

Tracking Reimbursement 459(164)

Tracking Reimbursement 460(1)

Getting Paid 460(3)

Explanation of Benefits 460(3)

Follow-up After Claim Submission 463(5)

Tracking Insurance Claims 463(1)

Analyzing Claim Problems 464(1)

Claim Inquiries 465(1)

Suspended and Denied Claims 466(1)

State Insurance Commission 466(2)

Review and Appeal Process 468(3)

Appeal 468(1)

Peer Review 469(2)

Follow-Up on Specific Claim Types 471(1)

Summation and Preview 471(10)
Appendices

Appendix A College Clinic-Medical Practice Simulation 481(4)

Appendix B College Clinic-Mock Fee Schedule 485(12)

Appendix C CPT Modifiers, Medicare's National HCPCS Level II Modifiers and Codes 497(8)

Appendix D HCFA-1500 Claim Form Block by Block Instructions and Insurance Templates 505(54)

Appendix E Glossary 559(14)

Appendix F College Clinic Form File 573(42)

Appendix G Student Software Challenge Installation and Operating Instructions 615(8)
Index 623