Comprehensive Health Insurance

Deborah Vines has worked extensively for more than 30 years in the healthcare industry as a practice administrator and manager in physical therapy, dermatopathology, and pediatrics. She has also held management positions in the hospital setting. As director of operations for a national healthcare staffing corporation, she has traveled across the United States, working directly with physicians and medical human resources personnel to secure jobs for individuals in the medical billing, coding, and collection fields. One of Ms. Vines’s mentionable achievements is that in one fiscal year, through mentoring and training, she assisted 300 recruits to find employment in the medical billing industry. This achievement led her to opening Allied Career Center in Dallas, Texas, a successful vocational school specializing in medical office specialist training. Ann Braceland, NCICS, has been working in the medical field since graduating from Gwynedd Mercy College with an associate’s degree in nursing science. As a practice manager, her extensive work in the field of managed care and medical billing and coding have allowed her to research and find means to inform others through her teaching of the changes and challenges that arise in the medical field. Mrs. Braceland has established and managed satellite offices in physical and occupational medicine. She is a Medicare representative with a vast spectrum of knowledge that she uses to train staff and physicians in compliance coding and billing. As director of training for the instructors of Allied Career Center in Dallas, Texas, her presentation of the material for students led to the publication of this book. Mrs. Braceland is a National Certified Insurance and Coding Specialist. Susan Miller has worked in the health care Industry for 25 years, managing and supervising medical billing processes. She has lectured in a classroom setting, providing students with knowledge and skills on medical billing and coding. Ms. Miller continues her health care career in Medical Billing, providing support to staff members on billing & coding guidelines.

SECTION I: A CAREER IN HEALTH CARE

1. Introduction to Professional Billing and Coding Careers

SECTION II: THE RELATIONSHIP BETWEEN THE PATIENT, PROVIDER, AND CARRIER

2. Understanding Managed Care: Insurance Plans

3. Understanding Managed Care: Medical Contracts and Ethics

4. Introduction to the Health Insurance Portability and Accountability Act (HIPAA)

SECTION III: MEDICAL CODING

5. ICD-10-CM Medical Coding

6. Introduction to CPT and Place of Service Coding

7. Coding Procedures and Services

8. HCPCS and Coding Compliance

9. Auditing

SECTION IV: MEDICAL CLAIMS

10. Physician Medical Billing

11. Hospital Medical Billing

SECTION V: GOVERNMENT MEDICAL BILLING

12. Medicare Medical Billing

13. Medicaid Medical Billing

14. TRICARE Medical Billing

SECTION VI: ACCOUNTS RECEIVABLE

15. Explanation of Benefits and Payment Adjudication

16. Refunds, Follow-Up, and Appeals

SECTION VII: INJURED EMPLOYEE MEDICAL CLAIM

17. Workers' Compensation



Appendix A: Completing the CMS-1500 Form for Physician Outpatient Billing 

Appendix B:  Completing the CMS-1500 Form for Physician Outpatient Billing Plus Determining the Correct Diagnostic and Procedure Codes 

Appendix C: Completing the UB-04 Form for Hospital Billing 

Appendix D: Medical Forms 

Appendix E: Acronyms and Abbreviations 

Appendix F: Medical Terminology Word Parts 

Appendix G: Helpful Websites 



Glossary 

Index