Fordney's Medical Insurance and Billing

16th Edition - October 27, 2021
Editor: Linda M. Smith
Language: English
Paperback ISBN:
9 7 8 - 0 - 3 2 3 - 7 9 5 3 5 - 7
eBook ISBN:
9 7 8 - 0 - 3 2 3 - 8 1 0 7 4 - 6

Gain the medical insurance skills you need to succeed in today’s outpatient and inpatient settings! Fordney's Medical Insurance and Billing, 16th Edition helps you master the insur… Read more

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Gain the medical insurance skills you need to succeed in today’s outpatient and inpatient settings! Fordney's Medical Insurance and Billing, 16th Edition helps you master the insurance billing specialist’s role and responsibilities in areas such as diagnostic coding, procedural coding, billing, and collection. Using clear, easy-to-understand explanations, this book covers all types of insurance coverage commonly encountered in hospitals, physicians’ offices, and clinics. Step-by-step guidelines lead you through medical documentation and administrative procedures. Written by coding specialist and educator Linda M. Smith, this market-leading text is a complete guide to becoming an efficient insurance billing specialist.

Cover Image
Title Page
Copyright
About the Author
Acknowledgements
Contributor and Reviewers
Welcome to the 16th Edition
Contents
Unit 1 Career Role and Responsibilities
1 Role of an Insurance Billing Specialist
OBJECTIVES
BACKGROUND OF INSURANCE CLAIMS, CODING, AND BILLING
ROLE OF THE INSURANCE BILLING SPECIALIST
MEDICAL ETIQUETTE
PROFESSIONAL ETHICS
SCOPE OF PRACTICE AND LIABILITY
FUTURE CHALLENGES
KEY POINTS
STUDENT ASSIGNMENT
2 Privacy, Security, and HIPAA
OBJECTIVES
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY
TRANSACTION AND CODE SETS
NATIONAL IDENTIFIERS
THE PRIVACY RULE: CONFIDENTIALITY AND PROTECTED HEALTH INFORMATION
PATIENT’S RIGHTS UNDER HIPAA
THE SECURITY RULE: ADMINISTRATIVE, TECHNICAL AND PHYSICAL SAFEGAURDS
HEALTH INFORMATION TECHNOLOGY FOR ECONOMIC AND CLINICAL HEALTH ACT
HIPAA Compliance Audits
CONSEQUENCES OF NONCOMPLIANCE WITH HIPAA AND HITECH
ORGANIZATION AND STAFF RESPONSIBILITIES IN PROTECTING PATIENT RIGHTS
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENTS
3 Compliance, Fraud, and Abuse
OBJECTIVES
COMPLIANCE DEFINED
FRAUD AND ABUSE LAWS
COMPLIANCE AUDITS AND OVERSIGHT
COMPLIANCE PROGRAMS
OIG COMPLIANCE PROGRAM GUIDELINES
WHAT TO EXPECT FROM THE HEALTH CARE ORGANIZATION
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENT
Unit 2 Introduction to Health Insurance
4 Basics of Health Insurance
OBJECTIVES
HISTORY OF HEALTH INSURANCE IN THE UNITED STATES
HEALTH CARE REFORM
LEGAL PRINCIPLES OF INSURANCE
THE INSURANCE POLICY
CHOICE OF HEALTH INSURANCE
TYPES OF HEALTH INSURANCE
HANDLING AND PROCESSING INSURANCE CLAIMS
LIFE CYCLE OF AN INSURANCE CLAIM
KEEPING UP TO DATE
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENT
5 The Blue Plans, Private Insurance, and Managed Care Plans
OBJECTIVES
PRIVATE HEALTH INSURANCE
MANAGED CARE
MANAGED CARE SYSTEMS
UTILIZATION MANAGEMENT
MANAGEMENT OF INSURANCE PLANS
REVENUE CYCLE MANAGEMENT
KEY POINTS
STUDENT ASSIGNMENT
6 Medicare
OBJECTIVES
BACKGROUND
POLICIES AND REGULATIONS
ADDITIONAL INSURANCE PROGRAMS
UTILIZATION AND QUALITY CONTROL
PROGRAM FUNDAMENTALS
MEDICARE REIMBURSEMENT
CLAIM SUBMISSION
AFTER CLAIM SUBMISSION
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENT
7 Medicaid and Other State Programs
OBJECTIVES
MEDICAID
MEDICAID PROGRAMS
MEDICAID ELIGIBILITY
MEDICAID BENEFITS
MEDICAID MANAGED CARE
ACCEPTING MEDICAID PATIENTS
CLAIMS PROCEDURES
AFTER CLAIMS SUBMISSION
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENT
8 TRICARE and Veterans’ Health Care
OBJECTIVES
TRICARE
HISTORY OF TRICARE
TRICARE HEALTH PLANS
TRICARE Prime Overseas
TRICARE Plus
VETERANS HEALTH ADMINISTRATION PROGRAM
TRICARE and VETERANS HEALTH ADMINISTRATION (CHAMPVA) CLAIMS PROCEDURES
AFTER CLAIM SUBMISSION
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENT
9 Workers’ Compensation
OBJECTIVES
WORKERS’ COMPENSATION DEFINED
HISTORY
WORKERS’ COMPENSATION INSURANCE PROGRAMS
ELIGIBILITY
FEDERAL AND STATE LAWS
TYPES OF STATE COMPENSATION BENEFITS
TYPES OF STATE WORKERS’ COMPENSATION CLAIMS
FRAUD AND ABUSE
LEGAL SITUATIONS
MEDICAL RECORD MANAGEMENT
REPORTING REQUIREMENTS
CLAIM SUBMISSION
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENT
10 Disability Income Insurance and Disability Benefit Programs
OBJECTIVES
DISABILITY INCOME INSURANCE DEFINED
HISTORY
DISABILITY INCOME INSURANCE POLICIES
FEDERAL DISABILITY PROGRAMS
STATE DISABILITY INSURANCE
DISABILITY INCOME CLAIMS SUBMISSION GUIDELINES
KEY POINTS
STUDENT ASSIGNMENTS
Unit 3 Documentation and Coding for Professional Services
11 Medical Documentation and the Electronic Health Record
OBJECTIVES
THE DOCUMENTATION PROCESS
GENERAL PRINCIPLES OF HEALTH RECORD DOCUMENTATION
DOCUMENTATION GUIDELINES FOR DIAGNOSES
DOCUMENTATION GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES
DOCUMENTATION GUIDELINES FOR SURGICAL SERVICES
DOCUMENTATION GUIDELINES FOR ANESTHESIA SERVICES
DOCUMENTATION GUIDELINES FOR RADIOLOGY SERVICES
DOCUMENTATION GUIDELINES FOR PATHOLOGY AND LABORATORY SERVICES
DOCUMENTATION GUIDELINES FOR MEDICAL SERVICES
RELEASE AND RETENTION OF RECORDS
ABSTRACTING FROM HEALTH RECORDS
REVIEW AND AUDIT OF HEALTH RECORDS
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENT
12 Diagnostic Coding
OBJECTIVES
DIAGNOSIS CODING OVERVIEW
INTERNATIONAL CLASSIFICATION OF DISEASES
ASSIGNING A DIAGNOSIS CODE
ORGANIZATION AND FORMAT OF ICD-10-CM
OFFICIAL GUIDELINES FOR ICD-10-CM
GENERAL CODING GUIDELINES
CHAPTER SPECIFIC CODING GUIDELINES
CODING AND REPORTING GUIDELINES FOR INPATIENT HOSPITAL CARE
COMPUTER-ASSISTED CODING
THE FUTURE OF DIAGNOSIS CODING
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENTS
13 Procedural Coding
OBJECTIVES
UNDERSTANDING THE IMPORTANCE OF PROCEDURAL CODING SKILLS
HEALTHCARE COMMON PROCEDURE CODING SYSTEM
CURRENT PROCEDURAL TERMINOLOGY CONTENT AND FORMAT
EVALUATION AND MANAGEMENT SERVICES (99202–99499)
ANESTHESIA SERVICES (00100–01999)
SURGERY GUIDELINES
RADIOLOGY (70010–79999)
PATHOLOGY AND LABORATORY (80047–89398)
MEDICINE (90281–99607)
CODE MODIFIERS
CORRECT CODING EDITS AND PRACTICES
METHODS OF PAYMENT
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENT
Unit 4 Claims Submission in the Medical Office
14 The Paper Claim CMS-1500
OBJECTIVES
THE PAPER CLAIM CMS-1500
TYPES OF SUBMITTED CLAIMS
ABSTRACTING FROM MEDICAL RECORDS
BASIC GUIDELINES FOR SUBMITTING A HEALTH INSURANCE CLAIM FORM (CMS-1500)
COMMON REASONS WHY CLAIM FORMS ARE DELAYED OR REJECTED
ADDITIONAL CLAIM SUBMISSION ERRORS
CLAIM COMPLETION GUIDELINES
INSTRUCTIONS FOR COMPLETING THE HEALTH INSURANCE CLAIM FORM (CMS-1500)
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENT
15 The Electronic Claim
OBJECTIVES
THE ELECTRONIC CLAIM
TRANSACTION AND CODE SETS REGULATIONS: STREAMLINING ELECTRONIC DATA INTERCHANGE
ELECTRONIC STANDARD HIPAA 837P
STANDARD UNIQUE IDENTIFIERS
BUILDING THE ELECTRONIC CLAIM
FOLLOW-UP OF ELECTRONIC CLAIMS PROCESSING
TRANSMISSION REPORTS
INTERNET RESOURCES
Unit 5 Revenue Cycle Management
16 Receiving Payments and Insurance Problem Solving
OBJECTIVES
REVENUE CYCLE MANAGEMENT
CLAIM POLICY GUIDELINES
EXPLANATION OF BENEFITS
CLAIM MANAGEMENT TECHNIQUES
CLAIM INQUIRIES
REVIEW AND APPEAL PROCESS
STATE INSURANCE COMMISSIONER
CLAIM DENIAL MANAGEMENT
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENT
17 Collection Strategies
OBJECTIVES
COLLECTION STRATEGIES
PATIENT EDUCATION
FEES
COLLECTING FEES
SELF-PAY BILLING
CREDIT AND COLLECTION LAWS
THE COLLECTION PROCESS
COLLECTION CONTROLS
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENT
Unit 6 Health Care Facility Billing
18 Introduction to Health Care Facilities and Ambulatory Surgery Centers
OBJECTIVES
HISTORY OF HEALTH CARE FACILITIES
TYPES OF HEALTH CARE FACILITIES
REGULATION OF HEALTH CARE FACILITIES
INPATIENT, OUTPATIENT AND NONPATIENT SERVICES
REVENUE CYCLE IN HEALTH CARE FACILITIES
REIMBURSEMENT METHODOLOGIES
QUALITY IN HEALTH CARE FACILITIES
Key Points
INTERNET RESOURCES
STUDENT ASSIGNMENT
19 Billing for Health Care Facilities
OBJECTIVES
INTRODUCTION TO FACILITIES BILLING
OUPATIENT AND INPATIENT DIAGNOSIS CODING GUIDELINES
INTRODUCTION TO INPATIENT FACILITY PROCEDURE CODING
CMS 1450/UNIFORM BILL UB-04
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENT
Unit 7 Employment
20 Seeking a Job and Attaining Professional Advancement
OBJECTIVES
EMPLOYMENT OPPORTUNITIES
PROFESSIONAL ORGANIZATIONS
JOB SEARCH
SELF-EMPLOYMENT
ATTAINING PROFESSIONAL ADVANCEMENT
KEY POINTS
INTERNET RESOURCES
STUDENT ASSIGNMENT
REFERENCEs
Key Abbreviations
Glossary
Index