Additional Information
Book Details
Abstract
A basic guide to hospital billing and reimbursement, Understanding Hospital Billing and Coding, 3rd Edition helps you understand, complete, and submit the UB-04 claim form that is used for all Medicare and privately insured patients. It describes how hospitals are reimbursed for patient care and services, showing how the UB-04 claim form reflects the flow of patient data from the time of admission to the time of discharge. Written by coding expert Debra P. Ferenc, this book also ensures that you understand the essentials of ICD-10-CM and develop skills in both inpatient coding and outpatient/ambulatory surgery coding.
- UB-04 Claim Simulation on the companion Evolve website lets you practice entering information from source documents into the claim form.
- Over 300 illustrations and graphics bring important concepts to life.
- Detailed chapter objectives highlight what you are expected to learn.
- Key terms, acronyms, and abbreviations with definitions are included in each chapter.
- Concept Review boxes reinforce key concepts.
- Test Your Knowledge exercises reinforce lessons as you progress through the material.
- Chapter summaries review key concepts.
- Practice hospital cases let you apply concepts to real-life scenarios.
- UPDATED content reflects the most current industry changes in ICD-10, MR-DRGs, PPS Systems, and the Electronic Health Record.
- NEW Hospital Introduction chapter includes a department-by-department overview showing how today’s hospitals really work
- NEW Health Care Payers and Reimbursement section follows the workflow of the hospital claim by including successive chapters on payers, prospect payment systems, and accounts receivable management.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| IFC\r | IFC | ||
| Understanding Hospital Billing and Coding\r | iii | ||
| Copyright | iv | ||
| Dedication | v | ||
| Preface | vii | ||
| Acknowledgments | xi | ||
| Editorial Review Board | xiii | ||
| Contents | xv | ||
| Section One - Hospital Overview\r | 1 | ||
| Chapter 1 - Hospital Introduction | 2 | ||
| HOSPITAL INTRODUCTION | 3 | ||
| EVOLUTION OF HOSPITALS | 4 | ||
| HISTORY OF HOSPITALS IN THE UNITED STATES | 8 | ||
| MODERN-DAY HOSPITAL DEVELOPMENT | 12 | ||
| HOSPITAL ORGANIZATIONAL STRUCTURE AND FUNCTIONS | 15 | ||
| DEPARTMENTAL FUNCTIONS | 17 | ||
| HOSPITAL CLASSIFICATIONS | 26 | ||
| HOSPITAL SERVICES | 28 | ||
| HOSPITAL SERVICE LEVELS | 28 | ||
| Glossary | 35 | ||
| Chapter 2 - Hospital Regulatory Environment | 37 | ||
| HOSPITAL REGULATION | 38 | ||
| FEDERAL LEGISLATION | 39 | ||
| FEDERAL REGULATORY AGENCIES | 44 | ||
| STATE REGULATIONS | 49 | ||
| STATE HOSPITAL LICENSING REQUIREMENTS | 50 | ||
| PURPOSE OF ACCREDITATION | 55 | ||
| ACCREDITATION PROCESS | 57 | ||
| NON-CLINICAL CREDENTIALS | 58 | ||
| Chapter 3 - Health Insurance Portability and Accountability Act (HIPAA) | 66 | ||
| HIPAA OVERVIEW | 67 | ||
| HIPAA LEGISLATION | 68 | ||
| HIPAA REGULATIONS | 74 | ||
| HIPAA TITLE II: ADMINISTRATIVE SIMPLIFICATION (HIPAA-AS) | 79 | ||
| HIPAA TITLE II: PRIVACY RULE | 85 | ||
| HIPAA TITLE II: SECURITY RULE | 91 | ||
| HIPAA COMPLIANCE | 93 | ||
| Section Two - Hospital Billingprocess | 101 | ||
| Chapter 4 - Patient Accounts and Data Flow | 102 | ||
| PATIENT ACCOUNTS AND DATA FLOW | 103 | ||
| PATIENT CARE PROCESS | 109 | ||
| PATIENT ADMISSION | 111 | ||
| ADMISSION PROCESS | 113 | ||
| MEDICAL RECORD DOCUMENTATION | 120 | ||
| PATIENT CARE SERVICES | 125 | ||
| CHARGE CAPTURE | 128 | ||
| PATIENT DISCHARGE | 130 | ||
| HOSPITAL BILLING PROCESS | 131 | ||
| ACCOUNTS RECEIVABLE (A/R) MANAGEMENT | 132 | ||
| Chapter 5 - Hospital Billing Process | 138 | ||
| PURPOSE OF THE BILLING PROCESS | 140 | ||
| PAYER GUIDELINES | 140 | ||
| CHARGE DESCRIPTION MASTER (CDM) | 150 | ||
| CODING SYSTEMS | 155 | ||
| CLAIM FORMS | 161 | ||
| HOSPITAL REVENUE CYCLE | 163 | ||
| Section Three - Coding\r | 175 | ||
| Chapter 6 - ICD-9-CM Diagnosis and Procedure Coding | 176 | ||
| HISTORY OF DIAGNOSIS CODING | 177 | ||
| PURPOSE OF DIAGNOSIS CODING | 180 | ||
| DIAGNOSIS CODING RELATIONSHIPS | 182 | ||
| ICD-9-CM CONTENT | 187 | ||
| ICD-9-CM OFFICIAL CONVENTIONS | 196 | ||
| STEPS TO CODING USING ICD-9-CM | 201 | ||
| ICD-9-CM OFFICIAL DIAGNOSIS CODING GUIDELINES | 205 | ||
| ICD-9-CM VOLUME III PROCEDURE CODING GUIDELINES | 209 | ||
| Chapter 7 - ICD-10-CM Diagnosis Coding | 217 | ||
| EVOLUTION OF DIAGNOSIS CODING | 218 | ||
| IMPACT OF ICD-10 | 220 | ||
| ICD-10-CM DATA USAGE | 229 | ||
| TRANSITION TO ICD-10-CM | 232 | ||
| ICD-10-CM CONTENT | 238 | ||
| ICD-10-CM OFFICIAL CONVENTIONS | 245 | ||
| STEPS TO CODING USING ICD-10-CM | 249 | ||
| Chapter 8 - Procedure Coding (HCPCS and ICD-10-PCS) | 259 | ||
| HISTORY OF PROCEDURE CODING | 261 | ||
| PROCEDURE CODING RELATIONSHIPS | 266 | ||
| PROCEDURE CODING SYSTEM VARIATIONS | 271 | ||
| HCPCS LEVEL I—CPT | 275 | ||
| HCPCS LEVEL II—MEDICARE NATIONAL CODES | 280 | ||
| INTERNATIONAL CLASSIFICATION OF DISEASES, 10TH REVISION, PROCEDURE CODING SYSTEM (ICD-10-PCS) | 285 | ||
| TRANSITION TO ICD-10 | 292 | ||
| STEPS TO CODING USING HCPCS AND ICD-10-PCS | 293 | ||
| Chapter 9 - Coding Guidelines and Applications: (HCPCS, ICD-10-PCS, and ICD-10-CM) | 306 | ||
| RELATIONSHIP BETWEEN BILLING AND CODING | 307 | ||
| CODING SYSTEM VARIATIONS | 313 | ||
| ICD-10-CM OFFICIAL DIAGNOSIS CODING GUIDELINES | 317 | ||
| HCPCS CODING GUIDELINES | 327 | ||
| ICD-10-PCS GENERAL CODING GUIDELINES | 334 | ||
| ICD-10-PCS OFFICIAL CODING GUIDELINES | 334 | ||
| STEPS TO CODING DIAGNOSES AND PROCEDURES | 340 | ||
| Section Four - Claim Forms\r | 351 | ||
| Chapter 10 - Claim Forms | 352 | ||
| PURPOSE OF CLAIM FORMS | 353 | ||
| CLAIM FORM SUBMISSION | 353 | ||
| CLAIM FORM VARIATIONS | 357 | ||
| CMS-1500 CLAIM FORM OVERVIEW | 359 | ||
| CMS-1450 (UB-04) CLAIM FORM OVERVIEW | 359 | ||
| Section Five - Health Care Payers Andreimbursement\r | 385 | ||
| Chapter 11 - Health Care Payers | 386 | ||
| TYPES OF HEALTH INSURANCE PLANS | 388 | ||
| THIRD-PARTY PAYERS | 395 | ||
| PRIVATE PAYERS | 395 | ||
| GOVERNMENT PAYERS | 397 | ||
| INSURANCE PLAN TERMS AND SPECIFICATIONS | 413 | ||
| Chapter 12 - Prospective Payment Systems (PPS) | 431 | ||
| PROSPECTIVE PAYMENT SYSTEMS (PPS) DEFINED | 432 | ||
| PROSPECTIVE PAYMENT SYSTEM (PPS) EVOLUTION | 432 | ||
| INPATIENT PROSPECTIVE PAYMENT SYSTEM (IPPS) | 436 | ||
| OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS) | 448 | ||
| Chapter 13 - Accounts Receivable (A/R) Management | 469 | ||
| LIFE CYCLE OF A HOSPITAL CLAIM | 470 | ||
| HOSPITAL BILLING PROCESS | 448 | ||
| ACCOUNTS RECEIVABLE (A/R) MANAGEMENT | 483 | ||
| CREDIT AND COLLECTION LAWS | 490 | ||
| COLLECTION ACTIVITIES | 492 | ||
| APPEALS PROCESS | 498 | ||
| Section Six - Appendixes | 505 | ||
| Appendix A - Cases | 506 | ||
| Appendix B - Claim Form Data | 565 | ||
| Contents | 565 | ||
| SECTION I: CMS-1450 (UB-04) COMPLETION INSTRUCTIONS FOR PAPER CLAIMS | 566 | ||
| SECTION II. CMS-1450 (UB-04) DATA CODE OPTIONS | 570 | ||
| SECTION III. CMS-1450 (UB-04) REVENUE CODE LISTING | 575 | ||
| Appendix C - List of Web Resources | 582 | ||
| CHAPTER 1 | 583 | ||
| CHAPTER 2 | 583 | ||
| CHAPTER 3 | 583 | ||
| CHAPTER 4 | 584 | ||
| CHAPTER 5 | 584 | ||
| CHAPTER 6 | 584 | ||
| CHAPTER 7 | 584 | ||
| CHAPTER 8 | 584 | ||
| CHAPTER 9 | 585 | ||
| CHAPTER 11 | 585 | ||
| CHAPTER 12 | 586 | ||
| CHAPTER 13 | 586 | ||
| Index | 587 |