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Understanding Health Insurance: A Guide to Billing and Reimbursement, 2023 Edition 18th edition [Minkštas viršelis]

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(Mohawk Valley Community College, Utica, New York)
  • Formatas: Paperback / softback, 704 pages, aukštis x plotis x storis: 27x215x274 mm, weight: 1428 g
  • Išleidimo metai: 17-Jan-2023
  • Leidėjas: Delmar Cengage Learning
  • ISBN-10: 0357764064
  • ISBN-13: 9780357764060
Kitos knygos pagal šią temą:
Understanding Health Insurance: A Guide to Billing and Reimbursement, 2023 Edition 18th editionDidesnis paveikslėlis
  • Formatas: Paperback / softback, 704 pages, aukštis x plotis x storis: 27x215x274 mm, weight: 1428 g
  • Išleidimo metai: 17-Jan-2023
  • Leidėjas: Delmar Cengage Learning
  • ISBN-10: 0357764064
  • ISBN-13: 9780357764060
Kitos knygos pagal šią temą:
Pastovi nuoroda: https://www.kriso.lt/db/9780357764060.html
Raktažodžiai:
Strengthen your skills and develop a solid foundation for professional success with Green's UNDERSTANDING HEALTH INSURANCE: A GUIDE TO BILLING AND REIMBURSEMENT, 2023 Edition. This reader-friendly, comprehensive resource provides a practical, up-to-date guide to current medical code sets and coding guidelines, preparing you to assign ICD-10-CM, CPT® and HCPCS Level II 2023 codes; complete health insurance claims; and master key revenue management concepts. You'll focus on important topics such as managed care, legal and regulatory issues, coding systems and compliance, reimbursement methods, clinical documentation improvement, coding for medical necessity and common health insurance plans. The current edition introduces the MIPS Value Pathways; explains major changes for selecting codes in the CPT 2023 evaluation and management section; and clarifies key health insurance concepts such as risk adjustments, hierarchical condition category coding, patient portals, balance billing, coordination of benefits, third-party administrators, Medicare appeals process and whistleblowers. In addition, a helpful workbook provides hands-on assignments and case studies, while MindTap online resources offer interactive practice in completing CMS-1500 claims and assigning codes.
Preface vii
About the Author xiii
Reviewers xiv
Acknowledgments xv
How to Use This Text xvi
Chapter 1 Health Insurance Specialist Career
1(21)
Health Insurance Overview
2(2)
Career Opportunities
4(1)
Education and Training
5(3)
Student Internship
6(2)
Job Responsibilities
8(1)
Health Insurance Specialist Job Description
8(1)
Independent Contractor and Employer Liability
9(2)
Professionalism
11(4)
Attitude, Self-Esteem, and Etiquette
11(1)
Communication
12(1)
Conflict Management
12(1)
Customer Service
12(1)
Diversity Awareness
12(1)
Leadership
12(1)
Managing Change
13(1)
Productivity
13(1)
Professional Ethics
13(1)
Team-Building
13(1)
Professional Appearance
14(1)
Telephone Skills for the Health Care Setting
15(3)
Professional Associations and Credentials
18(4)
Chapter 2 Introduction to Health Insurance and Managed Care
22(36)
Overview of Health Insurance and Managed Care
24(3)
State Insurance Regulators
26(1)
Health Insurance Coverage Statistics
27(1)
Major Developments in Health Insurance and Managed Care
27(6)
The First Health Insurance Plans
28(2)
Legislation and Regulations in the Twenty-First Century
30(1)
The Affordable Care Act
31(1)
Health Insurance Marketplace
32(1)
Managed Care
33(3)
Managed Care Organizations and Plans
33(1)
Managed Care Models
34(2)
Effects of Managed Care on a Physician's Practice
36(1)
Characteristics of Health Plans and Managed Care
36(6)
Primary Care Provider
37(1)
Quality Assurance and Performance Measurement
37(3)
Utilization Management
40(1)
Case Management
40(1)
Second Surgical Opinions
40(1)
Second and Third Opinions
40(1)
Prescription Management
40(2)
Consumer-Directed Health Plans
42(1)
Health Care Documentation
43(2)
Patient Records
43(1)
Problem-Oriented Record (POR)
44(1)
Electronic Health Record (EHR)
45(13)
Electronic Clinical Quality Measures
46(12)
Chapter 3 Introduction to Revenue Management
58(29)
Revenue Management
59(3)
Managing Patients
62(8)
Managing New Patients
62(7)
Managing Established Patients
69(1)
Encounter Form and Chargemaster
70(4)
Encounter Form
70(2)
Chargemaster
72(2)
Processing an Insurance Claim
74(4)
Management of Accounts Receivable
76(2)
Completing the CMS-1500 Claim
78(1)
Posting Charges to Patient Accounts
78(2)
Monitoring and Auditing for Revenue Management
80(7)
Quarterly Provider Updates
80(1)
Utilization Management and Case Management
81(1)
Revenue Monitoring
81(1)
Revenue Auditing
82(1)
Resource Allocation and Data Analytics
82(5)
Chapter 4 Revenue Management: Insurance Claims, Denied Claims and Appeals, and Credit and Collections
87(30)
Insurance Claim Cycle
88(14)
Claims Submission and Electronic Data Interchange (EDI)
89(5)
Claims Processing
94(1)
Claims Adjudication
95(4)
Remittance Advice Reconciliation and Payment of Claims
99(3)
Maintaining Insurance Claim Files
102(1)
Tracking Unpaid Claims
103(1)
Storing Remittance Advice Documents
103(1)
Denied Claims and the Appeals Process
103(4)
Appealing Denied Claims
104(3)
Credit and Collections
107(10)
Credit
108(1)
Collections
108(9)
Chapter 5 Legal Aspects of Health Insurance and Reimbursement
117(44)
Health Care Laws and Regulations
118(8)
Centers for Medicare and Medicaid Services
119(4)
Anti-Kickback Statutes
123(1)
Health Care Quality Legislation and Programs
124(2)
Retention of Records
126(1)
Health Care Audit and Compliance Programs
126(11)
Compliance Programs
127(1)
Medicare Integrity Program
128(2)
Medicaid Integrity Program
130(1)
Recovery Audit Contractor Program
131(1)
Health Care Fraud Prevention and Enforcement Action Team
132(1)
Medicare Shared Savings Program
133(1)
Reducing Overpayments Program
133(3)
National Correct Coding Initiative
136(1)
Health Insurance Portability and Accountability Act (HIPAA)
137(24)
HIPAA Title I---Health Care Access, Portability, and Renewability
138(1)
HIPAA Title II---Preventing Health Care Fraud and Abuse
139(1)
HIPAA Title II (continued-Administrative Simplification
140(15)
Title II (continued)---Medical Liability Reform
155(1)
Title III Tax-Related Health Provisions
155(1)
Title IV Application and Enforcement of Group Health Plan Requirements
156(1)
Title V Revenue Offsets Governing Tax Deductions for Employers
156(5)
Chapter 6 ICD-10-CM Coding
161(58)
Overview of ICD-10-CM and ICD-10-PCS
162(8)
ICD-10-PCS
164(1)
Coding Manuals
164(1)
Updating ICD-10-CM and ICD-10-PCS
164(3)
Mandatory Reporting of ICD-10-CM and ICD-10-PCS Codes
167(1)
Medical Necessity
167(1)
ICD-9-CM Legacy Coding System
168(2)
ICD-10-CM Index and Tabular List
170(19)
ICD-10-CM Index to Diseases and Injuries
170(14)
ICD-10-CM Tabular List of Diseases and Injuries
184(5)
Official Guidelines for Coding and Reporting
189(1)
ICD-10-CM Coding Conventions
190(10)
The Alphabetic Index and Tabular List
191(1)
Format and Structure
192(1)
Use of Codes for Reporting Purposes
192(1)
Placeholder Character
192(1)
Seventh Characters
193(1)
Abbreviations
193(1)
Punctuation
193(1)
Other and Unspecified Codes
194(1)
Includes Notes
195(1)
Inclusion Terms
195(1)
Excludes Notes
195(1)
Etiology and Manifestation Convention
196(1)
And
197(1)
With
197(1)
Cross References
198(1)
Code Also Note
199(1)
Default Code
199(1)
Code Assignment and Clinical Criteria
199(1)
Diagnostic Coding and Reporting Guidelines for Outpatient Services
200(19)
A Selection of First-Listed Condition
200(1)
B Codes from A00-T88.9, Z00-Z99, U00-U85
201(1)
C Accurate Reporting of ICD-10-CM Diagnosis Codes
201(1)
D Codes That Describe Signs and Symptoms
201(1)
E Encounters for Circumstances Other than a Disease or Injury (Z Codes)
202(1)
F Level of Detail in Coding
202(1)
G ICD-10-CM Code for the Diagnosis, Condition, Problem, or Other Reason for Encounter/Visit
202(1)
H Uncertain Diagnoses
203(1)
I Chronic Diseases
204(1)
J Code All Documented Conditions that Coexist
204(1)
K Patients Receiving Diagnostic Services Only
204(1)
L Patients Receiving Therapeutic Services Only
205(1)
M Patients Receiving Preoperative Evaluations Only
205(1)
N Ambulatory Surgery
205(1)
O Routine Outpatient Prenatal Visits
205(1)
P Encounters for General Medical Examinations with Abnormal Findings
206(1)
Q Encounters for Routine Health Screenings
206(13)
Chapter 7 CPT Coding
219(64)
Organization of CPT
220(10)
Relative Value Units
221(1)
CPT Categories
221(1)
CPT Sections
222(1)
CPT Code Number Format
222(1)
CPT Appendices
223(1)
CPT Symbols
224(3)
CPT Sections, Subsections, Categories, and Subcategories
227(3)
CPT Index
230(4)
Main Terms
230(1)
Modifying Terms
231(1)
Code Ranges
231(1)
Conventions
231(1)
Inferred Words
231(1)
Coding Procedures and Services
232(2)
CPT Modifiers
234(11)
Evaluation and Management Section
245(14)
Overview of Evaluation and Management Section
245(2)
Evaluation and Management Services Guidelines
247(6)
Evaluation and Management Subsections
253(6)
Anesthesia Section
259(4)
Assigning Anesthesia Codes
260(1)
Qualifying Circumstances for Anesthesia
260(1)
Anesthesia Modifiers
260(2)
Anesthesia Time Reporting
262(1)
Surgery Section
263(5)
Surgical Package
264(2)
Separate Procedure
266(2)
Radiology Section
268(3)
Complete Procedure
269(1)
Professional versus Technical Component
270(1)
Pathology and Laboratory Section
271(3)
Medicine Section
274(3)
CPT Category II and Category III Codes
277(6)
CPT Category II Codes
278(1)
CPT Category III Codes
278(5)
Chapter 8 HCPCS Level II Coding
283(18)
Purpose of HCPCS Level II Codes
284(2)
Responsibility for HCPCS Level II Codes
285(1)
Organization of HCPCS Level II Codes
286(5)
Permanent National Codes
286(1)
Miscellaneous Codes
287(1)
Temporary Codes
287(1)
Modifiers
288(1)
HCPCS Level II Index and Table of Drugs
289(1)
HCPCS Level II Code Sections
290(1)
Basic Steps for Using the HCPCS Level II Index and Code Sections
291(1)
Documentation and Submission Requirements for Reporting HCPCS Level II Codes
291(5)
Patient Record Documentation
293(1)
DMEPOS Requirements
294(2)
Assigning HCPCS Level II Codes and Modifiers
296(5)
Chapter 9 CMS Reimbursement Methodologies
301(45)
CMS Reimbursement
302(6)
Data Analytics
305(1)
Case-Mix Management
306(1)
CMS Payment Systems
307(1)
Changes to CMS Reimbursement Methods
308(1)
CMS Fee Schedules
308(9)
Ambulance Fee Schedule
308(1)
Clinical Laboratory Fee Schedule
309(1)
Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule
310(1)
Medicare Physician Fee Schedule
311(6)
CMS Payment Systems
317(29)
Ambulatory Surgical Center Payment System
317(2)
End-Stage Renal Disease Prospective Payment System (ESRD PPS)
319(1)
Federally Qualified Health Centers Prospective Payment System (FQHCPPS)
320(1)
Home Health Prospective Payment System
321(2)
Hospice Payment System
323(1)
Hospital Inpatient Prospective Payment System
324(9)
Hospital Outpatient Prospective Payment System
333(2)
Inpatient Psychiatric Facility Prospective Payment System
335(2)
Inpatient Rehabilitation Facility Prospective Payment System
337(1)
Long-Term (Acute) Care Hospital Prospective Payment System
337(2)
Skilled Nursing Facility Prospective Payment System
339(7)
Chapter 10 Coding Compliance Programs, Clinical Documentation Improvement, and Coding for Medical Necessity
346(37)
Coding Compliance Programs
347(6)
Comprehensive Error Rate Testing Program
348(1)
Medical Review (MR)
349(1)
National Correct Coding Initiative
350(3)
Recovery Audit Contractor Program
353(1)
Clinical Documentation Improvement
353(2)
DRG Coding Validation and Claims Denials
354(1)
Coding for Medical Necessity
355(9)
Applying Coding Guidelines
356(5)
Patient Record Documentation
361(1)
Coding and Billing Considerations
361(3)
Coding from Case Scenarios and Patient Records
364(19)
Coding from Case Scenarios
364(3)
Coding from Patient Records
367(5)
Reports
372(1)
Procedure for Coding Operative Reports
372(11)
Chapter 11 CMS-1500 and UB-04 Claims
383(44)
General Claims Information
384(6)
CMS-1500
387(1)
UB-04 (CMS-1450)
387(3)
Claims Attachments
390(1)
CMS-1500 Data Entry
390(13)
Entering Patient and Policyholder Names
392(1)
Entering Provider Names
392(1)
Entering Mailing Addresses
392(1)
Recovery of Funds from Responsible Payers
393(1)
National Provider Identifier (NPI)
393(3)
Assignment of Benefits versus Accept Assignment
396(1)
Reporting Diagnoses: ICD-10-CM Codes
396(2)
Reporting Procedures and Services: HCPCS Level II and CPT Codes
398(1)
CMS-1500 Block 24-Shaded Lines
398(4)
National Standard Employer Identifier
402(1)
Reporting the Billing Entity
403(1)
Processing Secondary or Supplemental CMS-1500 Claims
403(1)
Common Errors that Delay CMS-1500 Claims Processing
404(1)
Final Steps in Processing CMS-1500 Claims
405(1)
Maintaining CMS-1500 Claim Files
405(1)
Insurance File Set-Up
406(1)
Processing Assigned Paid Claims
406(1)
Federal Privacy Act
406(1)
UB-04 Claim
406(21)
UB-04 Claims and ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Level II Coding
407(1)
UB-04 Claim Development and Implementation
408(1)
UB-04 Claims Submission
408(11)
Correcting and Supplementing UB-04 Claims
419(8)
Chapter 12 Commercial Insurance
427(24)
Commercial Health Insurance
428(1)
Individual Health Insurance
428(1)
Group Health Insurance
428(1)
Automobile, Disability, and Liability Insurance
429(3)
Automobile Insurance
429(1)
Disability Insurance
429(1)
Liability Insurance
430(2)
Commercial Claims Instructions
432(8)
Commercial Secondary Claims Instructions
440(4)
Commercial Group Health Plan Claims Instructions
444(7)
Chapter 13 BlueCross BlueShield
451(23)
BlueCross BlueShield
452(2)
Origin of BlueCross and BlueShield
452(1)
BlueCross BlueShield Association
452(1)
Business Structure
453(1)
Network Participation and Utilization Management
453(1)
BlueCross BlueShield Plans
454(3)
Traditional Fee-for-Service Plans
455(1)
Indemnity Plans
455(1)
Managed Care Plans
455(1)
Federal Employee Program®
456(1)
Medicare Supplemental Plans
456(1)
Health Care Anywhere
457(1)
BlueCross BlueShield Billing Notes
457(1)
Claims Processing
457(1)
Deadline for Submitting Claims
457(1)
Claim Used
457(1)
Inpatient and Outpatient Coverage
458(1)
Deductible
458(1)
Copayment/Coinsurance
458(1)
Allowable Fee Determination
458(1)
Assignment of Benefits
458(1)
Special Handling
458(1)
BlueCross BlueShield Claims Instructions
458(8)
BlueCross BlueShield Secondary Claims Instructions
466(8)
Chapter 14 Medicare
474(52)
Medicare Eligibility and Enrollment
476(2)
Medicare Eligibility
476(1)
Medicare Enrollment
476(2)
Medicare Coverage
478(13)
Medicare Part A
478(3)
Medicare Part B
481(2)
Medicare Part C
483(3)
Medicare Part D
486(2)
Other Medicare Health Plans
488(1)
Medicare Savings Programs
489(1)
Medicare Shared Savings Program
489(1)
Employer and Union Health Plans
489(1)
Medigap
489(1)
Experimental and Investigative Procedures
490(1)
Medicare Participating, Nonparticipating, and Opt-Out Providers
491(3)
Participating Providers
491(1)
Nonparticipating Providers
491(2)
Opt-Out Providers
493(1)
Mandatory Claims Submission
494(1)
Advance Beneficiary Notice of Noncoverage
494(3)
Notice of Exclusion of Medicare Benefits
495(2)
Medicare as Primary and Secondary Payer
497(4)
Medicare as Primary Payer
497(1)
Medicare as Secondary Payer
498(3)
Medicare Summary Notice
501(1)
Medicare Billing Notes
502(1)
Medicare Administrative Contractor (MAC)
502(1)
Medicare Split/Shared Visit Payment Policy
502(1)
Durable Medical Equipment Claims
503(1)
Deadline for Submitting Claims
503(1)
Claims Used
503(1)
Medicare Crossover Program
503(1)
Special Handling
503(1)
Telehealth
504(1)
Medicare Claims Instructions
504(8)
Medicare and Medigap Claims Instructions
512(2)
Medicare-Medicaid (Medi-Medi) Crossover Claims Instructions
514(2)
Medicare as Secondary Payer Claims Instructions
516(3)
Medicare Roster Billing for Mass Vaccination Programs Claims Instructions
519(7)
Provider Enrollment Criteria
519(1)
Completing the CMS-1500 Claim for Roster Billing Purposes
519(7)
Chapter 15 Medicaid
526(29)
Medicaid Eligibility
527(4)
Medically Needy Program
528(1)
Special Groups
528(1)
Children's Health Insurance Program
529(1)
Programs of All-inclusive Care for the Elderly (PACE)
529(1)
Spousal Impoverishment Protection
529(1)
Confirming Medicaid Eligibility
530(1)
Medicaid Coverage
531(2)
Mandatory Medicaid Benefits
531(1)
Optional Medicaid Benefits
532(1)
Preventive Health Care Services
532(1)
Medicaid Reimbursement
533(5)
Medicare-Medicaid Relationship
534(1)
Medicaid as a Secondary Payer
534(1)
Participating Providers
534(1)
Medicaid and Managed Care
534(1)
Medicaid Eligibility Verification System
535(1)
Medicaid Remittance Advice
536(1)
Utilization Review
537(1)
Medical Necessity
537(1)
Medicaid Billing Notes
538(1)
Fiscal Agent
538(1)
Claim Used
538(1)
Timely Claims Submission Deadline
538(1)
Accept Assignment
538(1)
Deductibles
538(1)
Copayments
538(1)
Inpatient Benefits
538(1)
Major Medical/Accidental Injury Coverage
538(1)
Medicaid Eligibility
539(1)
Medicaid Cards
539(1)
Remittance Advice
539(1)
Medicaid Claims Instructions
539(7)
Medicaid Parent/Newborn Claims Instructions
546(3)
CHIP Claims Instructions
549(6)
Chapter 16 TRICARE
555(30)
TRICARE History
556(3)
TRICARE
557(1)
Transitional Health Care Options
558(1)
TRICARE Administration
559(2)
TRICARE Service Centers
559(1)
Military Treatment Facilities
560(1)
Case Management
560(1)
Program Integrity Office
560(1)
CHAMPVA
561(1)
Eligibility for CHAMPVA
561(1)
Veterans Choice Program
562(1)
TRICARE Coverage
562(3)
TRICARE Options
562(2)
TRICARE Special Programs
564(1)
Supplemental Health Care Programs
565(1)
TRICARE Billing Notes
565(4)
TRICARE Contractors
565(1)
Claim Used
565(1)
Claims Submission Deadline
566(1)
Allowable Fee Determination
566(1)
Deductibles
566(1)
Confirmation of Eligibility
566(1)
Accepting Assignment
566(2)
TRICARE Limiting Charges
568(1)
Special Handling
568(1)
Military Time
568(1)
TRICARE Claims Instructions
569(8)
TRICARE as Secondary Payer Claims Instructions
577(3)
TRICARE and Supplemental Coverage Claims Instructions
580(5)
Chapter 17 Workers' Compensation
585(25)
Federal and State Workers' Compensation Programs
586(3)
Federal Workers' Compensation Programs
586(2)
Federal Department of Labor Programs
588(1)
State Workers' Compensation Programs
589(1)
Eligibility for Workers' Compensation Coverage
589(1)
Classification and Billing of Workers' Compensation Cases
590(1)
Classification of Workers' Compensation Cases
590(1)
Billing Workers' Compensation Cases
591(1)
Workers' Compensation and Managed Care
591(1)
Forms and Reports
592(3)
First Report of Injury Form
592(3)
Appeals and Adjudication
595(2)
Fraud and Abuse
597(1)
Workers' Compensation Billing Notes
597(2)
Eligibility
597(1)
Identification Card
597(1)
Fiscal Agent
597(1)
Underwriter
597(1)
Forms and Claim Used
598(1)
Claims Submission Deadline
598(1)
Deductible
598(1)
Copayment
598(1)
Premium
598(1)
Approved Fee Basis
598(1)
Accept Assignment
599(1)
Special Handling
599(1)
Private Payer Mistakenly Billed
599(1)
Workers' Compensation Claims Instructions
599(11)
Appendix I Forms 610(3)
Appendix II Dental Claims Processing 613(1)
Dental Claims Processing 613(1)
Current Dental Terminology (CDT) 613(3)
Appendix III Abbreviations 616(5)
Bibliography 621(2)
Glossary 623(22)
Index 645
Michelle Green has served as a full-time or adjunct faculty member since 2017. During Spring 2023, Green was named interim Program Director in the Health Information Technology department at Mohawk Valley Community College in Utica, New York. She was the SUNY Distinguished Teaching Professor in the Physical and Life Sciences department at the State University of New York College of Technology at Alfred for over 30 years. She has authored three popular textbooks related to coding, revenue management and health information management. An active member of the AAPC and American Health Information Management Association, Green has been recognized for her excellence in teaching as well as her significant contributions to the health information management profession. Her numerous accolades include the State University of New York Chancellor's Award for Excellence in Teaching, Alfred State College's Alumni Association Teacher of the Year, Who's Who Among America's Teachers, AHIMA's FORE Triumph Educator Award and NYHIMAs Educator Award. In addition, she is a Registered Health Information Administrator, a fellow of the American Health Information Management Association and a Certified Professional Coder. She earned an MPS from Alfred University and a Bachelor of Science from Daemen College.