Insurance Coding and Electronic Claims for the Medical Office

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ISBN: 9780073053073 | 0073053074
Cover: Package
Copyright: 7/7/2005

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This text is structured to reflect a day in the life of an insurance codding and billing specialist. Using a "layered learning" concept, the student will move through the book in a logical progression, building upon each element learned at each stage of the reimbursement process. Students will learn to carefully glean pertinent data to code accurately from review and analysis of: a.) Superbills, b.) Provider's notes, c.) Referral authorization forms, and d.) New patient information forms.

Preface

viii

Insurance Overview

(14)

The Participants

(1)

Key Types of Insurance Plans

(5)

Health Maintenance Organization (HMO)

(1)

Preferred Provider Organization (PPO)

(1)

Point-of-Service (POS) Plan

(1)

Centers for Medicare & Medicaid Services (CMS)

(1)

TriCare/Champus/Champva

(1)

Other Insurance Plans

(2)

Methods of Payment to Your Office

(4)

Fee-for-Service (FFS) Plans

(1)

Capitation Plans

(1)

Episodic Care

(1)

Individual Insurance Contributions

(2)

Chapter Review

(3)

HIPAA's Privacy Rule Overview

(17)

Who Is Responsible for Obeying This Law

(1)

What This Law Covers

(11)

The Use and Disclosure of PHI

(1)

Getting Written Approval

(2)

Permitted Uses and Disclosures

(2)

Privacy Notices

(1)

Violating HIPAA's Privacy Rule

(3)

Chapter Review

(4)

Source Documents

(30)

Patient Registration Form

(7)

Insurance Card

(2)

Referral Authorization Form

(3)

Encounter Form and Superbill

(2)

Physician's Notes

(13)

Using Physician's Notes to Support Medical Necessity

(1)

Learning How to Understand Physician's Notes

(3)

Styles of Physician's Notes

(8)

Chapter Review

(2)

Introduction to Coding---Guidelines Overview

(19)

Seven Steps to Accurate Coding

(1)

Coding from Superbills Instead of Physician's Notes

(5)

ICD-9-CM Official Guidelines for Coding and Reporting

(1)

CPT Procedure Coding Guidelines

(1)

Rules for Ethical and Legal Coding

(7)

Chapter Review

(3)

Coding Diagnoses: ICD-9-CM

(37)

Getting Ready to Code

(3)

Three Categories of ICD-9-CM Diagnostic Codes

(4)

ICD-9-CM Codes

(1)

V Codes

(2)

E Codes

(2)

Three, Four, or Five Numbers---How Do You Know?

(6)

Three Digits

(1)

Four Digits

(1)

Five Digits

(4)

What to Code or Not Code

(7)

Notations and Explanations

103

(1)

Multiple and Additional Codes

103

(2)

Tables in the Alphabetic Listings (Volume 2)

105

(8)

Hypertension Table

105

(3)

Neoplasm Table

108

(3)

Table of Drugs & Chemicals

111

(2)

Too Much to Remember?

113

(2)

Chapter Review

115

(3)

Coding Diagnoses: ICD-10-CM

118

(14)

Introduction to ICD-10-CM

119

(1)

The Look of ICD-10-CM Codes

120

(1)

Length of Codes

120

(1)

Types of Characters

120

(1)

ICD-10-CM Code Descriptions

120

(8)

More Detailed Descriptions

120

(2)

Combination Codes

122

(1)

Z Codes---Formerly Known as V Codes

122

(1)

E (External) Codes

123

(1)

Notations and Explanations

123

(4)

ICD-10-CM Dummy Place Holders and Additional Characters

127

(1)

Complete ICD-10-CM Coding Guidelines

128

(2)

Chapter Review

130

(2)

Coding Procedures: CPT

132

(33)

Numerical Listings of CPT Codes

133

(1)

Coding and Reporting Guidelines

133

(1)

Alphabetic Index

133

(1)

Evaluation and Management Codes

134

(7)

Location

135

(1)

Relationship

135

(1)

Complexity/Time

136

(3)

Reading the Physician's Notes

139

(2)

The Numeric Listings in CPT

141

(5)

CPT Formatting

141

(1)

CPT Directional Symbols

142

(1)

CPT Directional Notations

143

(2)

CPT Instructional Notations

145

(1)

Using Documentation to Determine Procedure Codes

146

(5)

Modifiers

151

(8)

Evaluation and Management Modifiers

152

(1)

Surgical Modifiers

152

(2)

Procedure Modifiers

154

(1)

Laboratory Modifiers

155

(1)

Multiple Modifiers

156

(1)

Anesthesia Physical Status Modifiers

157

(1)

Modifiers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use

158

(1)

Category III Codes

159

(1)

Unlisted Codes

160

(1)

The Surgical Package

161

(2)

Chapter Review

163

(2)

Coding Procedures: ICD-9-CM Volume 3 and ICD-10-PCS

165

(17)

ICD-9-CM Volume 3

166

(7)

How Codes Are Structured

166

(1)

Coding Procedures Using ICD-9-CM, Volume 3

166

(7)

ICD-10-PCS

173

(6)

The Objectives for ICD-10-PCS

173

(1)

Notations in ICD-10-PCS

174

(1)

The Structure of ICD-10-PCS Codes

174

(1)

The ICD-10-PCS Book

175

(1)

ICD-10-PCS Character Order and Place Holders

176

(3)

Chapter Review

179

(3)

Complete Coding Practice: ICD-9-CM and CPT

182

(10)

Linking Diagnosis and Procedure Codes

183

(2)

Coding Practice

185

(7)

Physician's Notes for Marvin Doe

185

(1)

Physician's Notes for Roger Samuels

186

(1)

Physician's Notes for Patience Loyal

186

(1)

Physician's Notes for Wayne Johns

187

(1)

Physician's Notes for Mary Lou Sweet

187

(1)

Physician's Notes for Naomi Morgan

188

(1)

Physician's Notes for Harvey Practice

188

(1)

Physician's Notes for Marion Maxwell

189

(1)

Physician's Notes for Sarah Student

189

(1)

Physician's Notes for Paul Pepperstone

190

(1)

Physician's Notes for Mitzi Cagwell

190

(1)

Physician's Notes for Tex T. Books

191

(1)

Physician's Notes for Joan Smith-Doe

191

(1)

Health Insurance Claim Form CMS-1500

192

(26)

CMS-1500

193

(21)

Section 1: Top Left

193

(6)

Section 2: Top Right

199

(3)

Section 3: Bottom Left

202

(8)

Section 4: Bottom Right

210

(4)

UB-92 Form

214

(2)

Chapter Review

216

(2)

Electronic Claims Management: Using Patient Accounting Software

218

(69)

Benefits and Challenges of Electronic Claims Processing

219

(2)

One Mistake Can Equal a Thousand Errors

219

(1)

A Name Is Not a Name---Spelling Matters

219

(1)

One Number Off Is a Whole New Code

220

(1)

Types of Patient Accounting Software Programs

221

(1)

Entering Patient Data Using NDCMedisoft™ Advanced

222

(43)

Creating a New Practice

222

(2)

Entering a New Insurance Carrier

224

(2)

Entering a Patient's Employer

226

(2)

Entering Diagnosis Codes

228

(1)

Entering Procedure Codes

229

(4)

Practicing What You've Learned on Your Computer

233

(1)

Entering Attending Providers

233

(2)

Entering Referring Providers

235

(3)

Entering a New Patient

238

(5)

Entering a New Case

243

(9)

Entering Procedures and Patient Co-Payments

252

(5)

Printing a Receipt

257

(3)

Creating a Health Insurance Claim Form

260

(5)

Sending Claims Electronically

265

(11)

Chapter Review

276

(11)

Working with Insurance Companies

287

(15)

Working with Clearinghouses

288

(1)

Organizing Claims

289

(12)

Pile 1: Claims That Have Been Paid by the Insurers

290

(1)

Pile 2: Claims for Which You Have Received Denial Notices

291

(8)

Pile 3: Claims for Which You Have Received No Notices or Payment

299

(2)

Chapter Review

301

(1)

Receiving Revenues

302

(16)

Remittance Advice Review

303

(4)

Entering Insurance Payments into NDCMedisoft™ Advanced, Version 9

307

(7)

Capitation Payments

314

(2)

Chapter Review

316

(2)

Complete Coding and Claims Practice

318

(18)

Part I: Coding Practice

319

(11)

Bette Brothenheim

320

(2)

Scotty Mathison

322

(2)

Elise Dawson

324

(2)

Gregory H. Zolman

326

(2)

Halle A. Jackson

328

(2)

Part II: Claims Practice

330

(6)

Appendix A Abbreviations

336

(11)

Appendix B ICD-9-CM Official Guidelines for Coding and Reporting

347

(50)

Appendix C 1997 Documentation Guidelines for Evaluation and Management Services

397

(29)

Appendix D NDCMedisoft™ Advanced, Version 9---Issues and Answers

426

(6)

Glossary

432

(5)

Index

437

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Insurance Coding and Electronic Claims for the Medical Office

Summary

Table of Contents

Supplemental Materials