Medical Billing & Coding for Dummies
, by Smiley, Karen- ISBN: 9781119625445 | 1119625440
- Cover: Paperback
- Copyright: 12/5/2019
The definitive guide to starting a successful career in medical billing and coding
With the healthcare sector growing at breakneck speed—it’s currently the largest employment sector in the U.S. and expanding fast—medical billing and coding specialists are more essential than ever. These critical experts, also known as medical records and health information technicians, keep systems working smoothly by ensuring patient billing and insurance data are accurately and efficiently administered.
This updated edition provides everything you need to begin—and then excel in—your chosen career. From finding the right study course and the latest certification requirements to industry standard practices and insider tips for dealing with government agencies and insurance companies, Medical Billing & Coding For Dummies has you completely covered.
- Find out about the flexible employment options available and how to qualify
- Understand the latest updates to the ICD-10
- Get familiar with ethical and legal issues
- Discover ways to stay competitive and get ahead
The prognosis is good—get this book today and set yourself up with the perfect prescription for a bright, secure, and financially healthy future!
Karen Smiley, CPC, is a certified, multi-specialty coding expert in physician and outpatient reimbursement. With an extensive background as a coder, auditor, accounts receivable manager, and practice administrator, she has also served as an independent consultant to physician practices and as an assistant coding instructor.
Introduction 1
About This Book 1
Foolish Assumptions 2
Icons Used in This Book 2
Beyond the Book 3
Where to Go from Here 3
Part 1: Getting to Know Medical Billing and Coding 5
Chapter 1: Dipping Your Toes into Medical Billing and Coding 7
Coding versus Billing: They Really Are Two Jobs 8
Following a Day in the Life of a Claim 9
Keeping Abreast of What Every Biller/Coder Needs to Know 10
Complying with federal and state regulations 10
Learning the lingo: Medical terminology 11
Demonstrating medical necessity 11
Deciding Which Job Is Right for You 11
Examining your workplace options 12
Thinking about your dream job 12
Prepping for Your Career: Training Programs and Certifications 13
Previewing your certification options 13
Going back to school 14
Planning for the Future 15
Chapter 2: Exploring the Billing and Coding Professions 17
Looking at the Medical Coding Job 18
Verifying documentation 18
Following up on unclear documentation 21
Assigning diagnosis and procedure codes 21
Transforming visits into revenue 22
Determining whether medical coding suits you 23
Breaking Down the Medical Biller’s Job 23
Knowing the payers and keeping up on their idiosyncrasies 24
Billing each payer correctly 25
Checking the claim over prior to submission 27
Assessing whether medical billing is the right choice for you 27
In Tandem: Working Together or Doing Both Jobs Yourself? 28
Wearing both hats 28
Deciding which job is for you 29
Chapter 3: Weighing Your Employment Options 31
Choosing Your Environment: Doctor’s Office, Hospital, and Others 32
The doctor is in: Working in a physician’s office 33
Hooking up with a hospital 33
Focusing on a billing or practice management company 34
Processing claims for an insurance company 35
Considering the best of the rest 36
Getting your foot in the door 36
Remote Access: Setting up Off-Site 37
Working in your PJs 37
The no-commute commute: Arranging a suitable workspace 38
Looking at the downside of working remotely 38
Reviewing Other Work Options: Freelancing, Temping, and More 39
Heeding a Word of Advice for New Coders 40
Part 2: Boning Up on the Need-to-Knows of Your Profession 43
Chapter 4: Compliance: Understanding the Rules 45
You Rule! Meeting the Rule Makers 46
The Centers for Medicare & Medicaid Services (CMS) 46
The Office of Inspector General (OIG) 47
The individual payer (insurance company) 47
Complying with HIPAA 48
Doing your part: Do’s and don’ts of compliance 49
Uh-oh! Facing the consequences of non-compliance 53
Unbundling the Compliance Bundle 53
Looking at incidental procedures 54
Identifying when separately reporting is okay 54
Recognizing when unbundling’s not okay 55
Defining exclusivity 55
Getting the Most out of the Dreaded Audit 57
Distinguishing between internal and payer audits 58
Guarding against an RAC audit 58
Avoiding an audit: You can’t 59
Protecting yourself from an audit 59
Chapter 5: Not-So-Strange Bedfellows: Medical Terminology and Medical Necessity 61
Brushing Up on Basic Anatomy 62
Getting familiar with body systems 62
Getting a handle on illness and disease 64
Encountering injuries 64
Say What? Deciphering Medical Terminology 65
In the beginning: Knowing your prefixes 65
Sussing out the suffixes 67
Eureka! Putting them together 67
Understanding Medical Necessity 69
Scrubbing In: Proving Medical Necessity for Surgical Procedures 70
Checking out endoscopic procedures 70
Examining open surgical procedures 73
Understanding incidentals and when procedures can be separately reported 75
Using billing modifiers 75
Connecting with the World of Evaluation and Management Codes 76
Looking at what happens during the run-of-the-mill E&M visit 77
Visiting the office 78
Visiting the hospital 80
Dealing with consultation visits 82
Determining the level of billable service 83
Chapter 6: Getting to Know the Payers 85
Wading through Commercial Insurance Payers 86
Identifying the carriers 87
Tuning in to networks 89
Choosing third-party administrators 89
Medicare: Meeting the Chief Government Payer 90
Examining Medicare, part by part 91
Looking at Medicare supplement policies 93
Coding and processing Medicare claims 94
Working with Other Government Payers 95
Patient Protection and Affordable Care Act (ACA) 95
Medicaid 96
Tricare (Department of Defense) 98
CHAMPUS VA (Department of Veterans Affairs) 99
Office of Workers’ Compensation Programs (Department of Labor) 100
Part 3: Becoming a Professional: Getting Certified 103
Chapter 7: Your Basic Certification Options, Courtesy of the AAPC and AHIMA 105
Introducing the Two Main Credentialing Organizations: AAPC and AHIMA 106
Going with AAPC 106
Choosing AHIMA instead 106
Being a joiner: The benefits of membership 107
Joining one or both: The pros and cons of multiple membership 107
Looking at the Basic Certifications 108
AAPC and its basic certifications: CPC, COC, CPC-P, CIC 108
AHIMA and its basic certifications: CCA, CCS, CCS-P 110
Choosing the Certification That’s Right for You 111
Examining the educational requirements 112
Prioritizing your career needs 112
Seeing what employers in your area want 113
Examining the Exams: A Quick Review of the Main Tests 113
The CPC exam (AAPC) 114
The CCS exam (AHIMA) 116
The CCA exam (AHIMA) 117
Chapter 8: The Path to Certification: Finding a Study Program 119
The Big Picture: Thinking about Your Degree and Career Objectives 120
Prioritizing your career needs 120
Determining what kind of program better meets your needs 121
Deciding whether you want to pursue a degree 122
Considering the Time Commitment 122
Planning for your time-to-degree 122
Anticipating your day-to-day schedule 124
First Things First: Squaring Away Your Prerequisites 125
Preparing for your training program 125
Getting ready for the certification test 126
Picking a Program of Study 127
In your backyard: Community college 128
Vocation station: Technical school programs 130
Clicking the mouse: Online training 133
Caveat Emptor: Watching Out for Diploma Mills 136
Chapter 9: Signing Up and Preparing for the Certification Exam 139
Establishing a Study Routine and Strategy 139
Setting up your own space 140
Clearing your calendar for study 141
Developing a study strategy 141
Focusing on the Right Topics 142
Identifying body systems 143
Understanding medical terminology 148
Boning up on insurer and payer rules 150
Preparing Yourself for Test Day 151
Finding ways to stress less 151
Knowing how to use your resources 152
Signing Up for and Taking the Big Test 153
Taking a quick peek at the exam 154
Making the grade — or not 156
Tackling test-taking tips 156
Chapter 10: Adding Street Cred: Specialty Certifications and Continuing Ed 159
Introducing Specialty Certification Options 160
Eyeing AAPC trademarked certifications 160
Showing off specialty AHIMA certifications 160
Perusing the best of the rest 165
Building on Your Cred with Continuing Education 166
Adding up the continuing ed units (CEUs) 166
Earning the units you need 167
Digging up complimentary CEU resources 167
Getting the most bang for your buck with CEUs 168
Part 4: Dealing and Succeeding with Nitty-Gritty On-the-Job Details 171
Chapter 11: Processing a Run-of-the-Mill Claim: An Overview 173
Dreaming of the Perfect Billing Scenario 173
Completing the initial paperwork 174
Getting the documentation about the patient encounter with the provider 175
Entering the codes into the billing software 175
Show me the money! Letting the payer take its turn 176
Delving into the Details: Contract Specifics 177
Understanding who’s contracting whom? 177
Looking at standard contracts 178
Cutting through reimbursement rates and carve-outs 179
Covering Your Bases: Referrals and Preauthorization 179
Checking for referrals 180
Dealing with prior authorization 180
Tracking Your Claim from Submission to Payment 182
Working with billing software 182
Passing from provider to clearinghouse 183
And going on to the payer 185
Scoring the payment or going into negotiation 186
Fighting for Proper Payment: Filing an Appeal with the Payer 188
Chapter 12: Homing In on How to Prepare an Error-Free Claim 191
Assigning CPT Codes 192
Getting the lowdown on CPT codes and fee schedules 192
Knowing the rules governing which codes you can use 193
Linking your CPT codes to ICD-10-CM codes 194
Making your code as specific as possible 194
Paying attention to your bundle of joy 197
Applying Modifiers Correctly 199
Using modifiers for commercial payers 200
Managing modifiers for Medicare 201
Utilizing modifiers for other government payers 201
Using retired modifiers 202
Looking for Money Left on the Table 203
Turning a critical eye to the record 203
Overriding published edits 204
Setting the record straight: Physician queries 204
Checking and Double-Checking Your Documentation 206
Chapter 13: From Clearinghouse to Accounts Receivable to Money in the Pocket 209
Spending Time in the Clearinghouse 210
Scrub-a-dub-dub: Checking for errors 210
Matchmaker, matchmaker: Sending the claim to the right payer 210
Generating reports 211
Facing Factors Affecting Reimbursement Amounts 211
Understanding relative value units 211
Prioritizing procedures 213
Payment or Denial: Being in the Hands of the Payer 214
Reducing your time in accounts receivable 214
Overcoming rejection 216
Dealing with denial 216
Breaking Down the Remittance Advice 217
Getting familiar with the RA 217
Meshing the COB with the RA 218
Surveying subrogation 219
Chapter 14: Handling Disputes and Appeals 221
Dealing with Disputes Involving Contract and Non-Contracted Payers 221
Contract payers 222
Non-contracted payers 223
Knowing When to File an Appeal: General Guidelines 223
When general follow-up doesn’t yield a timely payment 224
When mix-ups in accounts receivable result in a delay 224
The Art of the Appeal: Understanding the Basics before You Begin 225
Recognizing who you’re dealing with 225
Knowing what to say and what not to say 226
Using the resources at your disposal 227
Going through an Appeal, Step by Step 228
Making the initial call 228
It’s in the mail: Composing an appeal letter 229
On the phone again: Following up when the check doesn’t arrive 232
Maxing out your appeals 234
Appealing Medicare Processing 236
Request for redetermination 236
Qualified Independent Contractor (QIC) reconsideration 236
Administrative Law Judge (ALJ) Hearing 237
Medicare Appeals Council and Judicial Review 238
Appealing a Workers’ Comp Claim 240
Chapter 15: Keeping Up with the Rest of the World 241
WHO’s on First: Providing Data to the World Health Organization 242
Charting Your Course with ICD 243
Understanding the differences between ICD-9 and ICD-10 244
Working on the 5010 platform 246
Moving beyond ICD-10 246
Part 5: Working with Stakeholders 249
Chapter 16: Dealing with Commercial Insurance Claims 251
Meeting Commercial Insurance 251
Noting big names in commercial insurance 252
Working with the major players 253
Cashing In with Commercial Payers 254
Determining reimbursement 254
Weaving through the ins and outs of pricing networks 255
Getting paid in- and out-of-network 257
Working your way around workers’ comp carriers 258
Finessing third-party administrators 259
Knowing What’s What: Verifying the Patient’s Plan and Coverage 261
Looking at the insurance card 261
Contacting the payer and/or network 262
Chapter 17: Caring about Medicare and Medicaid 263
Brushing Up on Medicare Basics 264
Working with Medicare Claims 264
Getting Medicare-approved 265
Processing Medicare claims 266
Deciding What Gets Paid 266
Going from local to national decision-making: LCDs and NCDs 266
Using an advance beneficiary notice (ABN) 267
Tracking the guidelines: The Medicare Coverage Database 268
Working with Medicare Contractors 269
Submitting your claims 269
Getting along with your Medicare rep 270
Doing Business with Medicare Part C Plans 270
Paying attention to plan differences 270
Turning to Uncle Sam for a helping hand 271
Verifying Coverage and Plan Requirements 271
Confirming plan specifics 272
Obtaining referrals and prior authorizations 273
Oops! Getting referrals and authorizations after the fact 274
Chapter 18: Coding Ethics: Being an Advocate for Your Employer 275
Playing the Part of the Professional Medical Biller/Coder 276
Dealing with patients 276
Working with payers 278
Providing positive feedback to colleagues 280
Protecting Yourself and Your Integrity 281
Surviving a sticky situation 281
Documenting your day 283
Mum’s the word: Keeping patient info private 284
Keeping yourself honest when you make a mistake 287
Getting the Most Bang for Your Client’s Buck — Honestly 287
Collecting payments from patients 287
Avoiding accusations of fraudulent billing 288
Part 6: The Part of Tens 291
Chapter 19: Ten Common Billing and Coding Mistakes and How to Avoid Them 293
Being Dishonest 293
Shifting the Blame 294
Billing More than Is Documented 294
Unbundling Incorrectly 294
Ignoring an Error 295
Mishandling an Overpayment 295
Failing to Protect Patients from Out-of-Network Penalties 296
Failing to Verify Prior Authorization 296
Breaking Patient Confidentiality 297
Following the Lead of an Unscrupulous Manager 297
Chapter 20: Ten Acronyms to Burn into Your Brain 299
ACA: Patient Protection and Affordable Care Act 300
ACO: Accountable Care Organization 300
CDI: Clinical Documentation Improvement 300
CMS: Centers for Medicare & Medicaid Services 301
EHR: Electronic Health Record 301
EOB: Explanation of Benefits 301
HIPAA: Health Insurance Portability and Accountability Act 302
INN: In-Network 302
NCCI: National Correct Coding Initiative 302
OON: Out-of-Network 303
Chapter 21: Ten (Plus One) Tips from Billing and Coding Pros 305
Insist on Proper Documentation 305
Verify Patient Benefits 306
Get Vital Patient Info at Check-In 306
Review the Documentation ASAP 306
Set Up a System to Ensure Accuracy 306
Play Nice with Others 307
Follow Up on Accounts Receivable Daily 307
Be a Bulldog on the Phone 307
Know Your Payer Contracts by Heart 308
Create a File System That Lets You Find What You Need 308
Make Payers Show You the Money! 309
Glossary 311
Index 319
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