Additional Information
Book Details
Abstract
A complete guide to insurance billing and coding, Insurance Handbook for the Medical Office, 13th Edition covers all the plans that are most commonly encountered in clinics and physicians’ offices. Its emphasis on the role of the medical insurance specialist includes areas such as diagnostic coding, procedural coding, Medicare, HIPAA, and bill collection strategies. Learning to fill in the claim form accurately is made easier by the use of icons for different types of payers, lists of key abbreviations, and numerous practice exercises. This edition provides the latest on hot topics such as ICD-10, healthcare reform, the new CMS-1500 form, and electronic claims. Trusted for more than 30 years, this proven reference from Marilyn Fordney prepares you to succeed as a medical insurance professional in any outpatient setting.
- Emphasis on the business of running a medical office highlights the importance of the medical insurance specialist in filing clean claims, solving problems, and collecting overdue payments.
- Key terms and key abbreviations are defined and emphasized, reinforcing your understanding of new concepts and terminology.
- Detailed tables, boxes, and illustrations call out key points and main ideas.
- Unique! Color-coded icons clarify information, rules, and regulations for different payers.
- An Evolve companion website enhances learning with performance checklists, self-assessment quizzes, and the Student Software Challenge featuring cases for different payer types and an interactive CMS-1500 form to fill in.
- A workbook contains learning tips, practice exercises for key terms and abbreviations, review questions, study outlines, performance objectives, a chapter with practice tests, and critical thinking activities for hands-on experience with real-world cases. Available separately.
- Updated coverage of key health insurance topics includes HIPAA compliance, the HITECH Act, health reform of 2010, electronic health records, electronic claims, ICD-10, NUCC standards, Physician Quality Reporting System (PQRS) Incentive Program, Meaningful Use, and CPT 2013.
- Updated ICD-10 coding information prepares you for the October 2014 ICD-10 implementation date.
- Updated content on claim forms includes block-by-block explanations and examples for the new CMS-1500 Claim Form.
- Updated guidelines for the filing and submission of electronic claims include sample screenshots and prepare you for the future of the medical office.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| IFC | IFC | ||
| Pageburst | ii | ||
| Insurance handbook for the Medical office | iii | ||
| Copyright | iv | ||
| Dedication | v | ||
| About the Author | vi | ||
| Welcome to the Thirteenth Edition | vii | ||
| PURPOSE | vii | ||
| CONTENT | viii | ||
| ORGANIZATION | ix | ||
| ANCILLARIES | ix | ||
| SUMMARY | xi | ||
| Acknowledgments | xiii | ||
| Contributors and Reviewers | xv | ||
| Contents | xvii | ||
| Unit 1 - Career Role and Responsibilities | 1 | ||
| Chapter 1 - Role of an Insurance Billing Specialist | 3 | ||
| OBJECTIVES | 3 | ||
| BACKGROUND OF INSURANCE CLAIMS, CODING, AND BILLING | 3 | ||
| ROLE OF THE INSURANCE BILLING SPECIALIST | 5 | ||
| MEDICAL ETIQUETTE | 15 | ||
| MEDICAL ETHICS | 15 | ||
| EMPLOYER LIABILITY | 18 | ||
| EMPLOYEE LIABILITY | 18 | ||
| SCOPE OF PRACTICE | 18 | ||
| FUTURE CHALLENGES | 19 | ||
| KEY POINTS | 19 | ||
| Internet Resources | 20 | ||
| Student Assignment | 20 | ||
| Chapter 2 - Compliance, Privacy, Fraud, and Abuse in Insurance Billing | 23 | ||
| OBJECTIVES | 23 | ||
| COMPLIANCE DEFINED | 23 | ||
| HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT | 24 | ||
| THE PRIVACY RULE: CONFIDENTIALITY AND PROTECTED HEALTH INFORMATION | 26 | ||
| THE SECURITY RULE: ADMINISTRATIVE, PHYSICAL, AND TECHNICAL SAFEGUARDS | 38 | ||
| HEALTH INFORMATION TECHNOLOGY FOR ECONOMIC AND CLINICAL HEALTH ACT | 38 | ||
| APPLICATION TO PRACTICE SETTING | 39 | ||
| FRAUD AND ABUSE LAWS | 40 | ||
| COMPLIANCE PROGRAM GUIDANCE FOR INDIVIDUAL AND SMALL GROUP PHYSICIAN PRACTICES | 45 | ||
| WHAT TO EXPECT FROM YOUR HEALTH CARE PRACTICE | 47 | ||
| KEY POINTS | 48 | ||
| Internet Resources | 49 | ||
| Student Assignment | 49 | ||
| Unit 2 - The Claims Process | 51 | ||
| Chapter 3 - Basics of Health Insurance | 53 | ||
| OBJECTIVES | 53 | ||
| HISTORY | 54 | ||
| INSURANCE IN THE UNITED STATES | 54 | ||
| HEALTH CARE REFORM | 54 | ||
| LEGAL PRINCIPLES OF INSURANCE | 56 | ||
| PHYSICIAN–PATIENT CONTRACTS AND FINANCIAL OBLIGATION | 57 | ||
| THE INSURANCE POLICY | 58 | ||
| CHOICE OF HEALTH INSURANCE | 60 | ||
| TYPES OF HEALTH INSURANCE COVERAGE | 64 | ||
| HANDLING AND PROCESSING INSURANCE CLAIMS | 67 | ||
| KEEPING UP TO DATE | 83 | ||
| KEY POINTS | 84 | ||
| Internet Resources | 85 | ||
| Student Assignment | 85 | ||
| Chapter 4 - Medical Documentation and the Electronic Health Record | 87 | ||
| OBJECTIVES | 87 | ||
| THE DOCUMENTATION PROCESS | 87 | ||
| INCENTIVE PROGRAMS FOR ADOPTION OF ELECTRONIC HEALTH RECORDS | 89 | ||
| GENERAL PRINCIPLES OF HEALTH RECORD DOCUMENTATION | 91 | ||
| DOCUMENTATION GUIDELINES FOR MEDICAL SERVICES | 92 | ||
| DOCUMENTATION TERMINOLOGY | 102 | ||
| ABSTRACTING FROM MEDICAL RECORDS | 110 | ||
| REVIEW AND AUDIT OF HEALTH RECORDS | 112 | ||
| RELEASE AND RETENTION OF HEALTH RECORDS | 114 | ||
| KEY POINTS | 124 | ||
| Internet Resources | 125 | ||
| Student Assignment | 125 | ||
| Chapter 5 - Diagnostic Coding | 127 | ||
| OBJECTIVES | 127 | ||
| DIAGNOSIS CODING FOR OUTPATIENT PROFESSIONAL SERVICES | 127 | ||
| INTERNATIONAL CLASSIFICATIONS OF DISEASES | 129 | ||
| ICD-10 DIAGNOSIS AND PROCEDURE CODES | 131 | ||
| ORGANIZATION AND FORMAT OF ICD-10-CM | 131 | ||
| OFFICIAL CODING GUIDELINES FOR ICD-10-CM | 134 | ||
| KEY POINTS | 152 | ||
| Internet Resources | 152 | ||
| Student Assignment | 153 | ||
| Chapter 6 - Procedural Coding | 155 | ||
| OBJECTIVES | 155 | ||
| UNDERSTANDING THE IMPORTANCE OF PROCEDURAL CODING SKILLS | 155 | ||
| METHODS OF PAYMENT | 158 | ||
| FORMAT AND CONTENT OF THE CPT CODE BOOK | 162 | ||
| HELPFUL HINTS IN CODING | 183 | ||
| CODE MODIFIERS | 185 | ||
| KEY POINTS | 205 | ||
| Internet Resources | 206 | ||
| Student Assignment | 206 | ||
| Chapter 7 - The Paper Claim CMS-1500 (02-12) | 209 | ||
| OBJECTIVES | 209 | ||
| Unit 3 - Health Care Payers | 375 | ||
| Chapter 11 - The Blue Plans, Private Insurance, and Managed Care Plans | 377 | ||
| OBJECTIVES | 377 | ||
| PRIVATE INSURANCE | 377 | ||
| MANAGED CARE | 378 | ||
| MANAGED CARE SYSTEMS | 380 | ||
| MEDICAL REVIEW | 384 | ||
| MANAGEMENT OF PLANS | 385 | ||
| PLAN ADMINISTRATION | 385 | ||
| FINANCIAL MANAGEMENT | 390 | ||
| KEY POINTS | 396 | ||
| Internet Resources | 396 | ||
| Student Assignment | 397 | ||
| Chapter 12 - Medicare | 399 | ||
| OBJECTIVES | 399 | ||
| BACKGROUND | 399 | ||
| POLICIES AND REGULATIONS | 400 | ||
| ADDITIONAL INSURANCE PROGRAMS | 409 | ||
| MEDICARE MANAGED CARE PLANS | 410 | ||
| UTILIZATION AND QUALITY CONTROL | 412 | ||
| PAYMENT FUNDAMENTALS | 413 | ||
| MEDICARE REIMBURSEMENT | 418 | ||
| CLAIM SUBMISSION | 421 | ||
| AFTER CLAIM SUBMISSION | 424 | ||
| BENEFICIARY REPRESENTATIVE/REPRESENTATIVE PAYEE | 425 | ||
| KEY POINTS | 431 | ||
| KEY POINTS—CONT’D | 432 | ||
| Internet Resources | 432 | ||
| Student Assignment | 432 | ||
| Chapter 13 - Medicaid and Other State Programs | 435 | ||
| OBJECTIVES | 435 | ||
| HISTORY | 435 | ||
| MEDICAID PROGRAMS | 436 | ||
| MEDICAID ELIGIBILITY | 438 | ||
| MEDICAID BENEFITS | 440 | ||
| MEDICAID MANAGED CARE | 443 | ||
| CLAIM PROCEDURES | 443 | ||
| AFTER CLAIM SUBMISSION | 446 | ||
| KEY POINTS | 449 | ||
| Internet Resources | 449 | ||
| Student Assignment | 449 | ||
| Chapter 14 - TRICARE and Veterans' Health Care | 451 | ||
| OBJECTIVES | 451 | ||
| HISTORY OF TRICARE | 451 | ||
| TRICARE PROGRAMS | 452 | ||
| TRICARE STANDARD | 453 | ||
| TRICARE EXTRA | 459 | ||
| TRICARE PRIME | 459 | ||
| TRICARE RESERVE SELECT | 461 | ||
| TRICARE RETIRED RESERVE | 461 | ||
| TRICARE YOUNG ADULT | 461 | ||
| TRICARE FOR LIFE | 461 | ||
| TRICARE PLUS | 462 | ||
| TRICARE PRIME REMOTE PROGRAM | 463 | ||
| SUPPLEMENTAL HEALTH CARE PROGRAM | 463 | ||
| TRICARE HOSPICE PROGRAM | 464 | ||
| TRICARE AND HMO COVERAGE | 465 | ||
| VETERANS HEALTH ADMINISTRATION PROGRAM | 465 | ||
| CLAIMS PROCEDURE | 467 | ||
| AFTER CLAIM SUBMISSION | 470 | ||
| KEY POINTS | 477 | ||
| Internet Resources | 477 | ||
| Student Assignment | 478 | ||
| Chapter 15 - Workers’ Compensation | 481 | ||
| OBJECTIVES | 481 | ||
| HISTORY | 481 | ||
| WORKERS’ COMPENSATION LAWS AND INSURANCE | 482 | ||
| ELIGIBILITY | 483 | ||
| COVERAGE | 484 | ||
| BENEFITS | 488 | ||
| TYPES OF STATE CLAIMS | 489 | ||
| FRAUD AND ABUSE | 491 | ||
| OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION ACT OF 1970 | 491 | ||
| LEGAL SITUATIONS | 494 | ||
| MEDICAL REPORTS | 497 | ||
| REPORTING REQUIREMENTS | 499 | ||
| CLAIM SUBMISSION | 503 | ||
| KEY POINTS | 513 | ||
| Internet ResourceS | 513 | ||
| Student Assignment | 514 | ||
| Chapter 16 - Disability Income Insurance and Disability Benefit Programs | 517 | ||
| OBJECTIVES | 517 | ||
| DISABILITY CLAIMS | 517 | ||
| HISTORY | 518 | ||
| DISABILITY INCOME INSURANCE | 518 | ||
| FEDERAL DISABILITY PROGRAMS | 520 | ||
| STATE DISABILITY INSURANCE | 523 | ||
| VOLUNTARY DISABILITY INSURANCE | 526 | ||
| CLAIMS SUBMISSION GUIDELINES | 526 | ||
| CONCLUSION | 528 | ||
| KEY POINTS | 541 | ||
| Internet Resources | 541 | ||
| Student Assignment | 541 | ||
| Unit 4 - Inpatient and Outpatient Billing | 543 | ||
| Chapter 17 - Hospital Billing | 545 | ||
| OBJECTIVES | 545 | ||
| HEALTH INSURANCE REIMBURSEMENT | 545 | ||
| PATIENT ACCOUNTS REPRESENTATIVE | 546 | ||
| ADMISSIONS PROCEDURES | 547 | ||
| UTILIZATION REVIEW | 552 | ||
| CODING HOSPITAL DIAGNOSES AND PROCEDURES | 553 | ||
| CODING INPATIENT PROCEDURES | 554 | ||
| CODING HOSPITAL OUTPATIENT PROCEDURES | 557 | ||
| INPATIENT MEDICAL BILLING PROCESS | 557 | ||
| REIMBURSEMENT PROCESS | 561 | ||
| OUTPATIENT INSURANCE CLAIMS | 564 | ||
| BILLING PROBLEMS | 565 | ||
| HOSPITAL BILLING CLAIM FORM | 565 | ||
| DIAGNOSIS-RELATED GROUPS | 567 | ||
| OUTPATIENT CLASSIFICATION | 568 | ||
| KEY POINTS | 584 | ||
| Internet Resources | 584 | ||
| Student Assignment | 585 | ||
| REFERENCES | 585 | ||
| Unit 4 - Employment | 587 | ||
| Chapter 18 - Seeking a Job and Attaining Professional Advancement | 589 | ||
| OBJECTIVES | 589 | ||
| EMPLOYMENT OPPORTUNITIES | 589 | ||
| JOB SEARCH | 590 | ||
| SELF-EMPLOYMENT | 601 | ||
| KEY POINTS | 612 | ||
| Internet Resources | 613 | ||
| Student Assignment | 613 | ||
| REFERENCES | 613 | ||
| Glossary | 614 | ||
| Key Abbreviations | 636 | ||
| Index | 640 | ||
| IBC\r | IBC |