Health Insurance Today - E-Book

Janet I. Beik

BOOK

Health Insurance Today - E-Book

Janet I. Beik

(2017)

Additional Information

Book Details

ISBN: 978-0-323-50957-2
Edition: 6
Language: English
Pages: 528
Subjects: Medical administration & management
Nursing & ancillary services
Medical study & revision guides & reference material

Abstract

Learn to comprehend the complexities of health insurance! Using a reader-friendly approach, Health Insurance Today, A Practical Approach, 6^th Edition gives you a solid understanding of health insurance, its types and sources, and the ethical and legal issues surrounding it. This new edition incorporates the latest information surrounding ICD-10, the Patient Protection and Affordable Care Act, and other timely federal influencers, as it guides you through the important arenas of health insurance such as claims submission methods, the claims process, coding, reimbursement, hospital billing, and more. Plus, with hands-on UB-04 and CMS-1500 (02-12) case studies on Evolve, you will come away with a clear understanding and working knowledge of the latest advances and issues in health insurance.

CMS-1500 (02-12) software with case studies gives you hands-on practice filling in a CMS-1500 (02-12) form electronically.
What Did You Learn? review questions ensure you understand the material already presented before moving on to the next section.
Imagine This! scenarios help you understand how information in the book applies to real-life situations.
Stop and Think exercises challenge you to use your critical thinking skills to solve a problem or answer a question.　
Clear, attainable learning objectives help you focus on the most important information and make chapter content easier to teach.
Chapter summaries relate to learning objectives, provide a thorough review of key content, and allow you to quickly find information for further review.
Direct, conversational writing style makes reading fun and concepts easier to understand.
HIPAA tips emphasize the importance of privacy and following government rules and regulations.

NEW! Updated content on the latest advances covers the most current information on Medicare, Electronic Health Records, Version 5010, and much more.
NEW! Expanded ICD-10 coverage and removal of all ICD-9 content ensures you stay up-to-date on these significant healthcare system changes.
NEW! UB-04 software and case studies gives you hands-on practice filling out electronic UB-04 forms.
NEW! UNIQUE! SimChart® for the Medical Office case studies gives you additional real-world practice.

Section Title	Page	Action	Price
Front Cover	Cover
Health Insurance Today: A Practical Approach	i
Health Insurance Today: A Practical Approach	iii
Copyright	iv
Advisory Board Members	v
Preface	vi
SPECIAL CHAPTER FEATURES	vi
What Did You Learn?	vi
Imagine This!	vi
Stop and Think	vi
HIPAA Tips	vi
Appendixes	vii
Evolve Resources	vii
Electronic Forms	vii
Guided Completion	vii
A Word About HIPAA	ix
About the Author	x
Acknowledgments	xi
Contents	xii
I - BUILDING A FOUNDATION	1
1 - THE ORIGINS OF HEALTH INSURANCE	1
WHAT IS INSURANCE?	2
HISTORY	3
KEY HEALTH INSURANCE ISSUES	7
Access to Health Insurance	7
Access to Health Insurance and the Law	7
State Programs for the Uninsured	8
Controlling Healthcare Costs	9
Healthcare Expenditures	9
Americans Are Living Longer Than Ever Before	9
Advances in Medical Technology	9
Rise in Chronic Diseases	9
More Demand for Healthcare	10
Media Intervention	10
Rising Medical Malpractice Premiums	10
Cost-Sharing	10
BASIC HEALTH INSURANCE PLANS	10
WEBSITES TO EXPLORE	12
REFERENCES AND RESOURCES	12
2 - TOOLS OF THE TRADE: A CAREER AS A HEALTH (MEDICAL) INSURANCE PROFESSIONAL	13
YOUR FUTURE AS A HEALTH INSURANCE PROFESSIONAL	14
Required Skills and Interests	14
Education	14
Preparation	15
JOB DUTIES AND RESPONSIBILITIES	17
CAREER PROSPECTS	18
Occupational Trends and Future Outlook	18
Step 1: Research Duties and Responsibilities. As mentioned previously, the student should be aware of the duties and responsibil...	19
Step 2: Enroll in a Formal Training Program. Education for health insurance professionals can vary, ranging from a diploma or ce...	19
Step 3: Become Certified. Numerous options are available for certification, depending on the employer’s preferences and the indi...	19
Step 4: Obtain Employment. In addition to physicians’ offices, insurance companies, hospitals, pharmacies, and government entiti...	19
Step 5: Learn and Perform Your Job Duties. It is important to study and learn the claims submission process from beginning to en...	19
Step 6: Posting Payments. All payments received, either from the insurer or from the patient, should be posted promptly to the p...	19
Step 7: Reporting Denied Charges to a Coding Specialist. The law requires that only certified coders make changes to a patient’s...	19
Step 8: Generate and Maintain a Log. It is recommended that health insurance professionals keep a detailed log of all conversati...	20
Step 9: Benefit from Job Security and Flexibility. Advances in electronic billing have made it possible for some health insuranc...	20
Home-Based Careers	20
Rewards	20
IS A CAREER IN HEALTHCARE RIGHT FOR YOU?	20
CERTIFICATION POSSIBILITIES	20
Electronic Claims	22
CMS-1500 (02/12) Universal Paper Form	22
?CLOSING SCENARIO	24
WEBSITES TO EXPLORE	24
REFERENCES AND RESOURCES	24
3 - THE LEGAL AND ETHICAL SIDE OF MEDICAL INSURANCE	25
MEDICAL LAW AND LIABILITY	27
Employer Liability	27
Employee Liability	27
INSURANCE AND CONTRACT LAW	27
Elements of a Legal Contract	27
Offer and Acceptance	28
Consideration	28
Legal Object	28
Competent Parties	28
Legal Form	28
Termination of Contracts	28
MEDICAL LAW AND ETHICS APPLICABLE TO HEALTH INSURANCE	29
IMPORTANT LEGISLATION AFFECTING HEALTH INSURANCE	29
Federal Privacy Act of 1974	29
Federal Omnibus Budget Reconciliation Act of 1980	30
Tax Equity and Fiscal Responsibility Act of 1982	30
Consolidated Omnibus Budget Reconciliation Act of 1986	30
Federal False Claim Amendments Act of 1986	30
Fraud and Abuse Act	30
Federal Omnibus Budget Reconciliation Act of 1987	30
The Patient Protection and Affordable Care Act	30
HIPAA’s Privacy Rule	30
MEDICAL ETHICS AND MEDICAL ETIQUETTE	31
Medical Ethics	31
Medical Etiquette	32
MEDICAL RECORD	32
Purposes of a Medical Record	32
Complete Medical Record	32
Who Owns Medical Records?	33
Retention of Medical Records	33
Access to Medical Records	33
Releasing Medical Record Information	33
DOCUMENTATION AND MAINTENANCE OF PATIENT MEDICAL RECORDS	35
Policy and Performance	35
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT AND COMPLIANCE	36
Impact of HIPAA	36
Impact on the Health Insurance Professional	36
Impact on Patients	37
Impact on Providers	38
Impact on Private Businesses	38
Enforcement of Confidentiality Regulations of HIPAA	38
Developing a Compliance Plan	38
CONFIDENTIALITY AND PRIVACY	38
Confidentiality	39
Privacy	39
Security	39
Exceptions to Confidentiality	39
Authorization to Release Information	40
Exceptions for Signed Release of Information	40
Medicaid-Eligible Patients and Workers’ Compensation Cases	40
Inpatient-Only Treatment	40
Court Order	40
Breach of Confidentiality	40
HEALTHCARE FRAUD AND ABUSE	41
Defining Fraud and Abuse	41
Who Commits Healthcare Insurance Fraud?	41
How Is Healthcare Fraud Committed?	42
How Do Consumers Commit Healthcare Insurance Fraud?	42
Preventing Fraud and Abuse	42
WEBSITES TO EXPLORE	44
REFERENCES AND RESOURCES	44
4 - HEALTHCARE REFORM: COVERAGE TYPES AND SOURCES	45
THE CHANGING FACE OF HEALTH INSURANCE	46
Reimbursement Models	47
Fee-for-Service (Indemnity)	47
Capitation	47
Resource-Based Relative Value Scale	47
Value-Based Care	47
Episode-of-Care	47
Out-of-Pocket Maximum and Lifetime Limits	48
Levels of Coverage	49
Limitations and Exclusions	49
Preventive Services	50
Standardized Benefits and Coverage Rule	50
Managed Care	50
THE HEALTH INSURANCE MARKETPLACE	51
MAJOR HEALTHCARE PAYERS	51
Medicaid	51
Medicare	52
TRICARE/CHAMPVA	52
Disability Insurance	52
Private	52
Social Security Disability Insurance	52
Workers’ Compensation	52
MISCELLANEOUS HEALTHCARECOVERAGE OPTIONS	53
Health Savings Account	53
Flexible Spending Account	53
Health Reimbursement Arrangements	53
Premium Reimbursement Arrangement	54
Health Insurance Exchanges	54
Accountable Care Organizations	54
Long-Term Care Insurance	54
Dental Care	54
Vision Care	54
CMS-1500 CLAIM FORM	55
CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT	56
HEALTH INSURANCE “WATCHDOGS”	56
OTHER TERMS COMMON TO THIRD-PARTY CARRIERS	57
Birthday Rule	57
Coordination of Benefits	57
Medical Necessity	58
UCR and Balance Billing	58
Participating versus Nonparticipating Providers	58
Miscellaneous Terms	58
II HEALTH INSURANCE BASICS	63
5 - Claim Submission Methods	63
OVERVIEW OF THE HEALTH INSURANCE CLAIMS PROCESS	64
Revisions to the CMS-1500 Form	65
Claim Form Completion Instructions	65
ELECTRONIC CLAIMS	65
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT	65
Electronic Transactions and Code Set Requirements	66
Privacy Requirements	66
Security Requirements	66
National Identifier Requirements	66
Major Improvements in Version 5010	68
Reasons for Updating the Standards	68
Impact of Version 5010 on Claims	68
Medicare’s Claim Submission Requirement	69
Essential Information for Claims Processing	71
Patient Information Form	71
New Patient Information	71
Insurance Section	73
Additional Insurance	73
Insurance Authorization and Assignment	73
Patient Insurance Identification Card	74
Patient Health Record	74
Encounter Form	75
Patient Ledger Card	78
ADVANTAGES OF ELECTRONIC CLAIMS	81
TWO WAYS TO SUBMIT ELECTRONIC CLAIMS	81
Claims Clearinghouses	81
Direct Claims	81
Clearinghouses versus Direct	82
THE UNIVERSAL CLAIM FORM (CMS-1500)	82
Optical Character Recognition	83
Using Optical Character Recognition Format Rules	83
Format of the Form	84
National Uniform Claim Committee Guidelines	84
Who Uses the Paper Form?	84
Proofreading	85
Claim Attachments	85
Tracking Claims	86
WEBSITES TO EXPLORE	88
REFERENCES AND RESOURCES	88
6 - NEW AND TRADITIONAL REIMBURSEMENT MODELS	89
FEE-FOR-SERVICE/INDEMNITY INSURANCE	90
HOW MEDICAL FEES ARE DETERMINED	92
Reasonable and Customary Fee	92
Resource-Based Relative Value Scale	93
Phasing Out Fee-for-Service	93
New Models of Healthcare Delivery	93
Integrated Delivery System	94
Accountable Care Organization	94
Patient-Centered Medical Home	94
Shared Savings	94
Episode of Care/Bundled Payments	94
Partial or Blended Capitation	94
HIPAA AND HEALTHCARE REFORM	95
Who Pays for Commercial Insurance?	96
Federal Employees Health Benefits Program	96
The New Self-Plus-One Option	96
High-Risk Pools and the Affordable Care Act	96
Employer Coverage Mandate	96
Health Insurance Exchanges	97
What Is Self-Insurance?	97
Employee Retirement Income Security Act of 1974	97
Third-Party Administrators/Administrative Services Organizations	97
Single or Specialty Service Plans	98
BLUE CROSS AND BLUE SHIELD	98
History of Blue Cross	98
History of Blue Shield	98
Blue Cross and Blue Shield Programs	99
BlueCard and BlueCard Worldwide	99
Federal Employees Health Benefits	99
Federal Employee Program	99
Medicare	99
Healthcare Service Plans	102
Medicare Supplement Plans	102
SUBMITTING BLUE CROSS AND BLUE SHIELD AND COMMERCIAL CLAIMS	103
Timely Filing	103
Filing Electronic Claims	103
Explanation of Benefits	104
Electronic Remittance Advice	104
WEBSITES TO EXPLORE	108
7 - THE CHANGING FACE OF MANAGED CARE	109
WHAT IS MANAGED CARE?	110
ORIGINS OF MANAGED CARE	111
GOALS OF MANAGED CARE	112
THE CHANGING FACE OF MANAGED CARE	112
MANAGED CARE’S CHALLENGES	112
Preferred Provider Organizations	113
Health Maintenance Organizations	114
Staff Model	114
Group Model	115
Network Model	115
Mixed Model	115
Direct Contract Model	115
Independent Practice Association	115
Full-Service HMO	115
Managed Behavioral Healthcare Organization	115
Other Types of Managed Care Organizations	115
Point of Service	116
Provider-Sponsored Organization	116
Exclusive Provider Organization	116
High-Deductible Plans	116
New Managed Care Products	116
Primary Care Preferred Provider Organizations	116
Integrated Delivery Systems	116
Managed Care and Medicaid	117
Managed Care and Medicare	117
National Committee for Quality Assurance	120
The Joint Commission	120
URAC	120
Utilization Review	120
Complaint Management	120
CLAIMS MANAGEMENT	121
Preauthorization and Precertification	121
Predetermination of Benefits	124
Predetermination Letter	124
Referrals	124
How a Patient Obtains a Referral	124
Referrals versus Consultations	124
HIPAA AND MANAGED CARE	126
IMPACT OF MANAGED CARE	126
FUTURE OF MANAGED CARE	127
WEBSITES TO EXPLORE	129
8 - UNDERSTANDING MEDICAID	130
WHAT IS MEDICAID?	132
Development of Medicaid	132
Federal and State Guidelines	132
State Participation	132
MEDICAID AND HEALTHCARE REFORM	133
Medicaid Eligibility	133
Medicaid Expansion Under the ACA	134
New Eligibility Group	134
Calculating Eligibility Using MAGI	135
Retroactive Eligibility	135
MEDICAID BENEFITS	136
Mandated Services	136
Optional Services	136
Categorically Needy	137
Medically Needy	137
Medicaid Cost Sharing	138
DUAL ELIGIBLE BENEFICIARIES	139
Dual Eligible Programs	139
Medicaid Savings Programs	139
OTHER MEDICAID PROGRAMS	140
Temporary Assistance for Needy Families	140
Children’s Health Insurance Program	140
Supplemental Security Income	140
SSI Eligibility	140
SSI Work Incentives	141
Ticket to Work	141
Plan to Achieve Self-Support	141
Community First Choice Option	142
Maternal and Child Health Services	142
Program of All-Inclusive Care for the Elderly	142
PRESCRIPTION DRUGS	143
Medicaid Drug Rebate Program	143
Prescription Drugs for Dual Eligibles	143
Community Call Plan and Emergency Waiver	144
Urgent Care Centers	144
ACCEPTING MEDICAID PATIENTS	144
Verifying Eligibility	144
Medicaid Identification Card	145
Automated Voice Response System	146
Electronic Data Interchange	146
Point-of-Sale Device	146
Computer Software Program	146
Benefits of Eligibility Verification Systems	146
Payment for Medicaid Services	146
Medically Necessary	147
Participating Providers	147
MEDICARE/MEDICAID RELATIONSHIP	147
PROCESSING MEDICAID CLAIMS	148
Submitting Medicaid Claims	149
Time Limit for Filing Medicaid Claims	149
Medicaid Secondary Claims	149
Resubmission of Medicaid Claims	149
Reciprocity	150
Common Medicaid Billing Errors	150
MEDICAID AND THIRD-PARTY LIABILITY	150
MEDICAID REMITTANCE ADVICE	151
SPECIAL BILLING NOTES	151
Accepting Assignment	151
Services Requiring Prior Approval	151
Preauthorization	153
What Is Medicaid Fraud?	153
Patient Abuse and Neglect	153
Recognizing Fraud and Abuse	154
MEDICAID QUALITY PRACTICES	154
Medicaid Integrity Program	154
THE HEALTH INSURANCE PROFESSIONAL’S ROLE	155
WEBSITES TO EXPLORE	157
REFERENCES AND RESOURCES	157
9 - CONQUERING MEDICARE’S CHALLENGES	158
THE MEDICARE PROGRAM	160
Medicare Enrollment	160
Medicare Administrative Contractor	161
Medicare Program Structure	161
Medicare Part A	161
Part A Costs and Eligibility	162
Part A Penalty	163
Medicare Part B	164
Part B Premiums and Cost-Sharing Requirements	164
Part B Penalty	166
Medicare Part C (Medicare Advantage Plans)	167
Types of Part C Plans	167
5-Star Plans	167
Medicare Part D (Prescription Drug Benefit Plans)	168
What Is TrOOP?	168
Medicare Part D and the ACA	169
Part D and Dual Eligibles	169
Changing Prescription Drug Coverage	169
Other Medicare Health Plans	169
Getting Help with Medicare Costs	169
What’s Important for Medicare in 2017	169
THE EFFECTS OF THE ACA ON MEDICARE COVERAGE	170
MEDICARE COMBINATION COVERAGES	170
Medicare/Medicaid Dual Eligibility	171
Medicare Supplement Policies	171
Medigap Insurance	171
Standard Medigap Policies	172
Medigap Eligibility	172
Medicare Secondary Payer	172
MEDICARE AND MANAGED CARE	173
Medicare HMOs	173
HMO with Point-of-Service Option	173
Preferred Provider Organization	173
Provider-Sponsored Organization	175
Private Fee-for-Service Plan	175
Special Needs Plans	175
Advantages	176
Disadvantages	176
PREPARING FOR THE MEDICARE PATIENT	177
Determining Medical Necessity	177
Advance Beneficiary Notice	178
LCDs and NCDs	180
Important Change Coming for HICNs	180
Replacing the Medicare Card	180
MEDICARE BILLING	181
Physician Fee Schedule	181
Value-Based Payment Modifier	181
Determining What Fee to Charge	182
FILING MEDICARE CLAIMS	182
Electronic Claims	183
Transition to ASC X12 Version 5010	183
Claim Status Request and Response	185
Submitting Claims with Attachments	185
Timely Filing Rules for Medicare Claims	185
CMS-1500 Completion Guidelines	187
Completing a Medigap Claim	187
Medicare Secondary Payer	187
Insurance Primary to Medicare	188
Completing Medicare Secondary Policy Claims	188
Medicaid Secondary Payer Conditional Payment	189
Medigap Crossover Program	190
Medicare/Medicaid Crossover Claims	190
Information Contained on the MSN	190
Medicare Remittance Advice	191
Standard Paper Remittance Advice	191
Electronic Remittance Advice	191
Enrolling in Electronic Remittance	191
Electronic Funds Transfer	191
MEDICARE AUDITS AND APPEALS	193
Audits	193
Recovery Audit Contractor Program	196
Appeals (Fee-for-Service Claims)	196
QUALITY REVIEW STUDIES	198
Quality Improvement Organizations	199
Quality Innovation Network (QIN)-QIOs	199
Beneficiary Notices Initiative	199
Beneficiary Complaint Response Program	199
Hospital-Issued Notice of Noncoverage and Notice of Discharge and Medicare Appeal Rights Reviews	199
Physician Review of Medical Records	200
Physician Quality Reporting System	200
MEDICARE BILLING FRAUD	200
Medicare Whistleblowers	200
CLINICAL LABORATORY IMPROVEMENT AMENDMENTS PROGRAM	201
WEBSITES TO EXPLORE	203
REFERENCES AND RESOURCES	204
10 - MILITARY CARRIERS	205
TRICARE	207
Defense Health Agency	207
TRICARE Regional Office	207
Military Health System	208
Military Treatment Facilities	208
TRICARE Regional Contractors	208
TRICARE Eligibility	208
Who Is Not Eligible for TRICARE?	209
Losing TRICARE Eligibility	209
TRICARE and the Affordable Care Act	209
TRICARE’s Three Basic Program Options	210
TRICARE Overseas Program	210
TRICARE Young Adult Program	210
What TRICARE Pays	211
TRICARE Standard Nonavailability Statement	212
TRICARE Dental Program	213
TRICARE Special Programs	213
Transitional Assistance Management Program	214
Exceptional Family Member Program	214
Extended Care Health Option	214
TRICARE Plus	214
TRICARE Pharmacy Program	214
TRICARE and Other Health Insurance	215
TRICARE Supplemental Insurance	215
TRICARE For Life	215
TRICARE For Life Eligibility	216
VERIFYING TRICARE ELIGIBILITY	216
Military Identification Cards	217
TRICARE PROVIDER TYPES	218
Provider Certification and Credentialing	218
Network and Non-Network Providers	219
TRICARE BENEFICIARY COST SHARING	220
TRICARE Coding and Payment System	220
TRICARE CLAIMS PROCESSING	221
Who Submits Claims	221
Submitting Paper Claims	222
Electronic Claims Submission	222
Deadline for Submitting Claims	222
TRICARE Explanation of Benefits	223
CHAMPVA	223
CHAMPVA and the Affordable Care Act	223
CHAMPVA Eligibility	223
Identifying CHAMPVA-Eligible Beneficiaries	226
CHAMPVA Benefits	227
CHAMPVA Beneficiary Cost Sharing	227
Non-VA Medical Care Program	227
CHAMPVA PROGRAM OPTIONS AND BENEFITS	227
In-House Treatment Initiative	228
Program for the Primary Family Caregiver	229
Foreign Medical Program	229
Veterans Affairs Dental Insurance Program	229
Prescription Drug Benefit	229
Meds by Mail Program	229
Durable Medical Equipment Benefit	229
Services Requiring Preauthorization	229
Summary of CHAMPVA Costs	230
Long-Term Care	230
Terminating CHAMPVA Benefits	230
CHAMPVA–TRICARE Connection	230
Health Plans Primary to CHAMPVA	230
CHAMPVA Supplement Plans	231
American Military Retirees’ Association (AMRA) CHAMPVA Supplement Plan	231
CHAMPVA–Medicare Connection	231
CHAMPVA and HMO Coverage	232
CHAMPVA Policy on Balance Billing	233
CHAMPVA for Life	233
CHAMPVA for Life Eligibility	233
CHAMPVA for Life and Medicare	233
FILING CHAMPVA CLAIMS	234
Electronic Claims	234
Claims Filing Deadlines	234
Claims Filing Summary	235
CHAMPVA Explanation of Benefits	235
Claims Appeals and Reconsiderations	235
MILITARY CARRIERS AND HIPAA	237
WEBSITES TO EXPLORE	239
11 - MISCELLANEOUS CARRIERS: WORKERS’ COMPENSATION AND DISABILITY INSURANCE	240
WORKERS’ COMPENSATION	242
History	242
Division of Federal Employees’ Compensation	242
Division of Energy Employees Occupational Illness Compensation	243
Division of Longshore and Harbor Workers’ Compensation	243
Division of Coal Mine Workers’ Compensation	243
Federal Employers Liability Act	243
The Merchant Marine Act	243
The Patient Protection and Affordable Care Act and Workers’ Compensation Premium Determination	243
Workers’ Compensation Requirements	243
Eligibility	244
Exemptions	244
Job Categories	244
Business Owners and Executives	244
Benefits	244
Denial of Benefits and Appeals	246
Time Limits	246
Workers’ Compensation Claims Process	246
First Report of Injury	247
Attending Physician’s Role	247
Determining Disability	247
Vocational Rehabilitation	251
Waiting Periods	251
Claim Forms	251
Progress Reports	252
Special Billing Notes	252
Workers’ Compensation and Medicare	252
Workers’ Compensation Medicare Set-Aside Arrangements	252
Workers’ Compensation and Medicaid	252
Workers’ Compensation and Managed Care	254
HIPAA and Workers’ Compensation	254
Workers’ Compensation Fraud	254
Defining Disability	255
Short-Term Disability	255
Long-Term Disability	255
Disability Claims Process	255
Employee’s Responsibilities	255
Employer’s Responsibilities	259
Attending Physician’s Statement	259
Health Insurance Professional’s Role	259
FEDERAL DISABILITY PROGRAMS	259
Americans with Disabilities Act	260
Social Security Disability Insurance	260
History of the SSDI Program	260
Administration and Funding	260
Eligibility	260
Supplemental Security Income	261
Administration and Funding	261
Eligibility	261
Income Limit for SSI	261
Compassionate Allowances Program	262
State Disability Programs	262
Centers for Disease Control and Prevention	262
Ticket to Work and Self-Sufficiency Program	263
Filing SSDI and SSI Claims	263
Patient’s Role	263
Physician’s Role	264
Health Insurance Professional’s Role	264
WEBSITES TO EXPLORE	266
III - CRACKING THE CODES	267
12 - DIAGNOSTIC CODING	267
INTRODUCTION TO THE INTERNATIONAL CLASSIFICATION OF DISEASES CODING SYSTEM	268
Two Major Coding Structures	269
HISTORY AND DEVELOPMENT OF THE INTERNATIONAL CLASSIFICATION OF DISEASES CODING SYSTEM	269
Uses of Coded Data	270
Why the Change to ICD-10-CM?	270
ICD-10-CM Coding and Reporting Guidelines	271
PROCESS OF CLASSIFYING DISEASES	271
OVERVIEW OF THE ICD-10 CODING SYSTEM	273
ICD-10-CM Code Structure	273
Format of the ICD-10-CM Manual	273
Alphabetic Index	274
Main Terms	274
Essential and Nonessential Modifiers	275
Conventions Used in the Alphabetic Index	277
Parentheses	278
Cross-References (See and See Also)	278
TABULAR LIST	279
Format and Structure of Codes	280
Placeholder Character	280
Seventh (7th) Character	281
Tabular List Conventions	282
Abbreviations	282
NEC (Not Elsewhere Classifiable)	282
NOS (Not Otherwise Specified)	282
Punctuation	282
Brackets	282
Parentheses	282
Colons	282
Dashes	282
Point Dash	283
Instructional Notes	283
Manifestation Codes	284
Etiology/Manifestation Convention (“Code First,” “Use Additional Code,” and “In Diseases Classified Elsewhere” Notes)	284
“Code Also” Note	284
Morphology Codes	285
Default Codes	285
Section II: Selection of Principal Diagnosis	286
Section III: Reporting Additional Diagnoses	286
A: Selection of First-Listed Diagnosis	286
1: Outpatient Surgery	286
2: Observation Stay	286
B: Codes from A00.0 through T88.9, Z00–Z99	287
C: Accurate Reporting of ICD-10-CM Diagnosis Codes	287
D: Codes that Describe Symptoms and Signs	287
E: Encounters for Circumstances Other Than a Disease or Injury	287
F: Level of Detail in Coding	287
G: ICD-10-CM Code for the Diagnosis, Condition, Problem, or Other Reason for the Encounter/Visit	287
H: Uncertain Diagnosis	287
I: Chronic Diseases	287
J: Code All Documented Conditions that Coexist	287
K: Patients Receiving Diagnostic Services Only	287
L: Patients Receiving Therapeutic Services Only	287
M: Patients Receiving Preoperative Evaluations Only	288
N: Ambulatory Surgery	288
O: Routine Outpatient Prenatal Visits	288
P: Encounters for General Medical Examinations with Abnormal Findings	288
Q: Encounters for Routine Health Screenings	288
Combination Codes	288
Late Effects (Sequelae)	289
Impending or Threatened Condition	289
Laterality	289
Table of Drugs and Chemicals	289
Adverse Effects	289
Underdosing	290
Coding for External Causes of Morbidity	290
Alphabetic Index of External Causes	290
Combination Codes in Chapter 19	290
CODING STEPS FOR THE TABULAR LIST	291
HIPAA AND CODING	291
Code Sets Adopted as HIPAA Standards	291
GENERAL EQUIVALENCE MAPPINGS	292
IMPLEMENTATION OF ICD-10-CM	292
WEBSITES TO EXPLORE	294
REFERENCES AND RESOURCES	294
13 -Procedural, Evaluation and Management,and HCPCSCoding	296
OVERVIEW OF CURRENT PROCEDURAL TERMINOLOGY CODING	297
Three Levels of Procedural Coding	298
Current Procedural Terminology Manual Format	299
Category II Codes	300
Category III Codes	300
Appendices A through O	300
Current Procedural Terminology Index	300
Main Terms	300
Modifying Terms	301
Code Ranges	301
Modifiers	301
Unlisted Procedure or Service	302
Special Reports	302
Importance of the Semicolon	303
Cross-Referencing with See	303
Documentation Requirements	306
Three Factors to Consider	307
Key Components	307
History	307
Examination	308
Medical Decision-Making	308
Contributing Factors	308
Prolonged Services	309
Prolonged Service Without Direct Patient Contact	309
Standby Services	309
Office or Other Outpatient Services	310
Hospital Observation Services	310
Hospital Inpatient Services	311
Consultations	312
Emergency Department Services	313
Critical Care Services	313
Nursing Facility Services	313
Reasons for Using Modifiers	314
Importance of Documentation	314
Preventing Medical Billing and Coding Errors	314
Deciding Which Guidelines to Use	315
Overview of HCPCS	315
HCPCS Level II Manual	316
Index of Main Terms	316
Table of Drugs	317
Modifiers	317
Sections of the HCPCS Manual	317
Appendices	317
National Correct Coding Initiative	318
HIPAA and HCPCS Coding	318
Crosswalk	318
The CPT-5 Project	319
WEBSITES TO EXPLORE	321
REFERENCES AND RESOURCES	321
IV - THE CLAIMS PROCESS	322
14 - THE PATIENT	322
PATIENT EXPECTATIONS	323
Professional Office Setting	324
Relevant Paperwork and Questions	324
Honoring Appointment Times	324
Patient Load	325
Privacy and Confidentiality	325
Financial Issues	325
FUTURE TRENDS	326
Aging Population	326
Internet as a Healthcare Tool	326
Patients as Consumers	326
HIPAA REQUIREMENTS	327
Authorization to Release Information	327
HIPAA and Covered Entities	327
HIPAA Requirements for Covered Entities	327
HIPAA Transaction 5010	328
Changes to the CMS-1500 Form	328
Patient’s Right of Access and Correction	328
Affordable Care Act’s Patient’s Bill of Rights	328
BILLING POLICIES AND PRACTICES	331
Assignment of Benefits	331
Keeping Patients Informed	331
Establishing a Billing Policy	331
Accounting Methods	332
“One-Write” or Pegboard Accounting System	334
Electronic Patient Accounting Software	334
Electronic Medical Records	335
BILLING AND COLLECTION	335
Billing Cycle	337
Arranging Credit or Payment Plans	337
Self-Pay Patients	337
Terminating the Patient–Provider Relationship	337
Establishing Credit	337
Problem Patients	338
Truth in Lending Act	339
Fair Credit Billing Act	339
Equal Credit Opportunity Act	339
Fair Credit Reporting Act	339
Fair Debt Collection Practices Act	339
COLLECTION METHODS	339
Collection by Telephone	339
Timetable for Calling	339
Selecting Which Patients to Call	340
Collection by Letter	340
BILLING SERVICES	340
COLLECTION AGENCIES	341
SMALL CLAIMS LITIGATION	342
Who Can Use Small Claims	342
How the Small Claims Process Works	342
?CLOSING SCENARIO	344
WEBSITES TO EXPLORE	344
REFERENCES AND RESOURCES	345
15 - KEYS TO SUCCESSFUL CLAIMS MANAGEMENT	346
KEYS TO SUCCESSFUL CLAIMS	348
First Key: Collect and Verify Patient Information	348
Second Key: Obtain Necessary Preauthorization and/or Precertification	349
Third Key: Documentation	350
Fourth Key: Follow Payer Guidelines	350
Fifth Key: Proofread Claim to Avoid Errors	350
Sixth Key: Submit a Clean Claim	350
Rejected Claims Versus Denied Claims	351
CLAIM PROCESS	352
Step One: Claim Is Received	352
Step Two: Claims Adjudication	352
Step Three: Tracking Claims	352
Creating a Suspension File System	352
Creating an Insurance Claims Register System	354
Step Four: Receiving Payment	354
Troubleshooting the Explanation of Benefits	357
Downcoding	359
Step Six: Posting Payments	359
Time Limits	359
PROCESSING SECONDARY CLAIMS	360
Real-Time Claims Adjudication	362
APPEALS	362
Incorrect Payments	362
Denied Claims	363
Appealing a Medicare Claim	363
WEBSITES TO EXPLORE	365
REFERENCES AND RESOURCES	365
V - ADVANCED APPLICATION	366
16 - THE ROLE OF COMPUTERS IN HEALTH INSURANCE	366
INTRODUCTION	367
IMPACT OF COMPUTERS ON HEALTH INSURANCE	367
ELECTRONIC DATA INTERCHANGE	368
Benefits of Electronic Data Interchange	369
ELECTRONIC CLAIMS PROCESS	369
Enrollment	369
Electronic Claims Clearinghouse	369
Direct Data Entry Claims	370
Clearinghouse Versus Direct	370
Advantages of Filing Claims Electronically	371
Medicare Claims and the “Rule”	371
Exceptions to the “Rule”	371
Electronic Funds Transfer	372
Electronic Remittance Advice	373
ELECTRONIC MEDICAL RECORD	373
Combination Records	376
Digital Imaging Hybrid	376
Potential Issues	376
Incompatible Systems	376
Security Issues	376
Future of Electronic Medical Records	376
Need for a Comprehensive Solution	377
Components of Meaningful Use	378
WEBSITES TO EXPLORE	380
REFERENCES AND RESOURCES	380
17 - REIMBURSEMENT PROCEDURES: GETTING PAID	381
UNDERSTANDING REIMBURSEMENT SYSTEMS	382
Types of Reimbursement	383
Fee-for-Service	383
Discounted Fee-for-Service	383
Prospective Payment System	383
Relative Value Units	384
Relative Value Scale	384
Resource-Based Relative Value Scale	384
Managed Care Organizations	384
Capitation	384
MEDICARE AND REIMBURSEMENT	385
Medicare Prospective Payment System	385
Acute Inpatient Prospective Payment System	386
Outpatient Prospective Payment System	386
Skilled Nursing Facility Prospective Payment System	386
Home Health Prospective Payment System	387
Inpatient Rehabilitation Facility Prospective Payment System	387
Inpatient Psychiatric Facility Prospective Payment System	387
Long-Term Care Hospital Prospective Payment System	387
Hospice Payment System	387
Medicare Advantage Program (CMS Hierarchical Condition Category)	387
Value-Based Payment Modifier	388
Diagnosis-Related Groups	388
How Diagnosis-Related Groups Work	388
Assigning a Diagnosis-Related Group to a Patient	388
Calculating Diagnosis-Related Group Payments	389
Ambulatory Payment Classifications	389
Outpatient Code Editor	389
Calculating Ambulatory Payment Classification–Based Fees	389
Pass-Through Payments	390
Resource Utilization Groups	390
Establishing Medicare Payment Policy	391
Case-Level Adjustment	391
Nonmedical Peer Review Organizations	392
Managing Transactions	393
Posting and Tracking Patient Charges	393
Processing Payments	393
Insurance Carrier Adjustments (Contractual Write-Offs)	393
Generating Reports	394
Accounts Receivable Aging Report	395
Insurance Claims Aging Report	395
Practice Analysis Report	395
HIPAA AND PRACTICE MANAGEMENT SOFTWARE	396
WEBSITES TO EXPLORE	401
REFERENCES AND RESOURCES	401
18 - HOSPITAL BILLING AND THE UB-04	402
INTRODUCTION	404
MODERN HOSPITAL AND HEALTH SYSTEMS	404
Emerging Issues	405
COMMON HEALTHCARE FACILITIES	405
Integrated Delivery System	406
Acute Care Facility	406
Critical Access Hospital	406
Ambulatory Surgery Centers	406
Clinic	407
Other Types of Healthcare Facilities	407
Subacute Care Facility	407
Skilled Nursing Facility	407
Intermediate Care Facility	408
Long-Term Care Facility	408
Hospice	408
Home Health Agency	408
LEGAL AND REGULATORY ENVIRONMENT	408
Accreditation	409
The Joint Commission	409
National Committee for Quality Assurance	409
Accreditation Association for Ambulatory Health Care	409
Utilization Review Accreditation Commission	410
HIPAA	410
Professional Standards	410
Governance	410
Confidentiality and Privacy	410
Fair Treatment of Patients	411
Patient’s Bill of Rights Under the Affordable Care Act	412
Medicare	412
Quality Improvement Organizations	413
Keeping Current With Medicare	413
Medicare Part A: Review	413
Qualifying for Medicare Part A	413
What Medicare Part A Pays	413
How Medicare Part A Payments Are Calculated	414
Medicare Severity System	414
Inpatient Prospective Payment System 3-Day Payment Window	414
Medicaid	414
TRICARE	415
CHAMPVA	415
Blue Cross and Blue Shield	415
Private Insurers	416
Medicare Claims Processing Manual	418
UB-04 Data Specifications	418
Billing Rules	418
837I: Electronic Version of the UB-04 Form	418
Data Layout of the 837I	418
National Uniform Billing Committee Codes	419
Establishing a Hospital Information System	420
Standard Codes and Terminology	421
INPATIENT HOSPITAL/FACILITY CODING	421
ICD-10-PCS	421
Structure of ICD-10-PCS Codes	422
Format of the ICD-10-PCS	422
Selecting the Principal Diagnosis	422
Secondary Diagnoses	424
Skill Requirements for ICD-10-PCS Coding	425
Rule Changes Affecting Hospital Billing	425
The 72-Hour Rule	425
Hospital Value-Based Purchasing Program	425
OUTPATIENT HOSPITAL CODING	426
Ambulatory Payment Classifications	426
Ambulatory Payment Classification Payment Rate	426
Grouper Software System	427
Medicare Outpatient Code Editor	427
National Correct Coding Initiative	427
Informed Consent	429
Present on Admission	430
Hospital Charges	430
Hospital Charge Description Master	430
Electronic Claims Submission	431
Benefits of Electronic Claims Submission for Hospital Charges	431
Health Information Management Systems	431
Payment Management	432
HIPAA–HOSPITAL CONNECTION	432
BILLING COMPLIANCE	433
Coding Compliance	434
Job Outlook	434
WEBSITES TO EXPLORE	438
REFERENCES AND RESOURCES	438
A - Sample Blank CMS-1500 (02/12)	439
B - CMS-1500 Claim Forms and Completion Instructions	441
C - UB-04 Claim Forms andCompletion Instructions	463
Glossary	467
Index	490
A	490
B	491
C	491
D	494
E	495
F	496
G	497
H	497
I	499
J	500
K	500
L	500
M	501
N	503
O	503
P	503
Q	505
R	505
S	506
T	507
U	508
V	508
W	508
X	508

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