Comprehensive Health Insurance

Deborah Vines has worked extensively for over 20 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 to secure jobs for individuals in the medical billing, coding and collection fields.  A mentionable achievement of Ms. Vines’ is in one fiscal year she assisted 300 recruits find employment in this industry through mentoring and training. This achievement led her to open a successful vocational school specializing in medical office specialist training.   Ann B. Braceland has been working in the medical field since graduation from Gwynedd Mercy College is 1964 with an associate's degree in nursing. As a practice manager she has demonstrated the ability to adopt to changes to the challenges that arise in medical billing, coding and managed care contracts. Mrs. Braceland has established and managed offices in Physical Medicine and Occupational Medicine. These experiences led her to teaching skills. She is now highly regarded for training physicians and medical personnel in compliance coding, billing as well as medical office management. She was a Medicare representative and Director of Training of Allied Career School in Dallas, TX. Her teaching and lectures has formed the basis of this subsequent text.   Elizabeth Rollins, NCICS began her career in a nationally renowned multi-office pediatric ophthalmology practice. She worked in every position, from medical receptionist and appointment scheduling, to medical records and insurance claims submission, before being promoted to Insurance/Collection Manager. She completed insurance claims by hand and typed the patient billing statements for four years until the practice became computerized. As a Certified Account Manager for a national healthcare staffing corporation, Elizabeth met with hospitals, physicians, clinics and CBOs to assess their employment needs and showcase her roster of employees ready for hire. Elizabeth is a National Certified Insurance and Coding Specialist as well as the Director and an Instructor at a vocational school where she enjoys meeting with, teaching and encouraging students on a daily basis.   Susan Miller, NCICS has 20 years experience in the medical field and currently specializes in dialysis billing.  She was previously a Lead Instructor at a vocational school, preparing students for a career in the medical field as medical office specialists.  She has acted as a supervisor at insurance companies and worked one-on-one with policyholders to assist them in having a better understanding of health insurance.  In 2004 she obtained the title of National Certified Insurance & Coding Specialist.  She also holds certificates from Career Colleges and schools of Texas and Brookhaven College for Interactive Leadership Skills for Educators.

Preface

 

Section I — A Career in Healthcare

 

CHAPTER 1: INTRODUCTION TO PROFESSIONAL BILLING AND CODING CAREERS

 

Employment Demand

 

Facilities

Physician Practice

 

Hospital

 

Centralized Billing Office

 

Job Descriptions

 

Medical Office Assistant          

 

Medical Biller

           

Medical Coder

 

Registered Health Information Technicians (RHIT)

           

Payment Poster           

 

Medical Collector        

 

Refund Specialist         

 

Insurance Verification Representative

           

Admitting Clerk or Front Desk Representative 

 

Patient Information Clerk         

 

Professional Memberships

 

Certification

 

Medical Office Assistant Certification

 

Medical Billing Certifications

 

 

Medical Coding Certifications

 

Medical Records Certification

 

 

Resources

 

 

Section II:  Relationship between the Patient, Provider and Carrier

 

CHAPTER 2: MANAGED CARE TERMINOLOGY

 

 

The History of Healthcare in America

 

Medical Reform

 

Definition of Managed Health Care

 

Managing and Controlling Cost

              Discounted Fees  

Patient Care Delivered Is Medically Necessary

 

Care Rendered By Appropriate Provider

 

Appropriate Medical Care in Least Restrictive Setting

 

Withholding Providers’ Funds

 

Insurance Plans  

            Commercial Health Insurance

 

Types of Managed Care Organizations

                        Health Maintenance Organizations (HMO)               Preferred Provider Organization (PPO)  

            Point Of Service Options (POS)

 

Criticism of MCOs

 

Alternative Health Care Plans

 

Exclusive Provider Organization (EPO)

              Independent Physician Association (IPA)               Physician-Hospital Organization (PHO)  

            Self-insured Employers  

Types of Insurance Coverage

 

        Hospital  

         Hospital Indemnity Insurance  

         Medical                Surgical  

        Outpatient  

Major Medical  

Special Risk  

Catastrophic Health Insurance

 

Short-Term Health Insurance

 

Cobra Insurance

 

Full-Service Health Insurance

 

Long-Term Care

  Supplemental Insurance

 

The Provider’s View of Managed Care

 

Restrictions

 

Opportunities

 

Patient Care  

Facility Operations  

Collection of Funds

 

Assignment of Benefits

 

 

CHAPTER 3: UNDERSTANDING MANAGED CARE: MEDICAL CONTRACTS AND ETHICS

 

Purpose of a Contract

 

A Legal Agreement

  Compensation and Billing Guidelines   Covered Medical Expenses  

            Payment

 

Ethics in Managed Care   Changes in Health Care Delivery

 

Ethics of the Medical Office Specialist

 

Contract Definitions

 

Compensation for Services

 

Patient Bill of Rights

 

 

Section III: Medical Coding

 

 

CHAPTER 4: ICD-9 MEDICAL CODING

 

Definitions of Diagnosis Coding  

History of Diagnosis Coding

 

Purpose of ICD-9-CM

 

Addenda

 

The Future of Diagnostic Coding: ICD-10-CM

 

The Three Volumes of the ICD-9-CM

          Volume I: Tabular/Numerical List of Diseases             Volume II: Alphabetic Index of Diseases

 

            Volume III: Tabular and Alphabetic Index of Procedures

 

Proper Use of the ICD-9-CM

 

            ICD-9-CM Conventions

 

The Alphabetic Index- Volume 2  

Supplementary Terms

 

Introduction to Volume I

           

            The Tabular List: Volume I

                       

How to Code

 

Key Coding Guidelines

 

Primary Diagnosis First, Followed by Current Coexisting Conditions

Code to Highest Level of Certainty

Code to the Highest Level of Specificity

Surgical Coding

Coding Late Effects

Acute and Chronic Conditions

 

Combination Code — Multiple Coding

 

 

V Codes

 

E Codes

 

Supplemental Classification of External Causes of Injury and Poisoning

 

Neoplasm Table

 

The Fifth-digit Behavior Codes

 

Coronary Artery Disease

 

Ischemic Heart Disease

 

Hypertension Table

 

Poisoning and Adverse Effects of Drugs

 

Burns

 

Diabetes

 

Injuries, Complications and Accidents

 

Fractures

 

Other Scenarios

 

Nine Steps for Accurate ICD-9-CM Coding

 

  CHAPTER 5: INTRODUCTION TO CPT AND PLACE OF SERVICE CODING

 

CPT  

CPT Categories

           

            Category I

 

            Category II

           

            Category III

 

CPT Nomenclature

 

            Symbols

 

            Guidelines

 

Modifiers  

List of Modifiers for Evaluation and Management Coding

 

Coding to the Place of Service

 

Office vs. Hospital Services

 

Emergency Department Services

 

Preventive Medicine Service

 

Type of Patient

 

New Patient

 

Established Patient

 

Referral  

Consultation  

Level of E/M Service

 

Extent of Patient’s History

 

Extent of Examination

 

Complexity of Medical Decision Making

 

Additional Components

 

            Assigning the Code

 

 

CHAPTER 6: CODING PROCEDURES AND SERVICES

  Organization of the CPT Index               Instructions for Using the CPT  

Format of the Terminology  

Format

 

Cross-references

 

Section Guidelines

 

Modifiers

 

Coding Steps

           

            Coding for Anesthesia

 

Surgical Coding  

Add-On Codes (+)  

Separate Procedure

 

Surgical Package or Global Surgery Concept

 

Supplies and Services

           

Post-op Follow up   99024

 

Radiology Codes

 

Pathology and Laboratory Codes

 

Medicine

 

 

CHAPTER 7: HCPCS AND CODING COMPLIANCE

 

History of HCPCS

 

HCPCS Level of Codes

 

Level I — CPT

 

Level II - HCPCS National Codes

 

Level III — Local Codes

 

HCPCS Modifiers  

    The Use of the GA Modifier

 

Index

 

Coding Linkage and Coding Compliance

 

Code Linkage

 

Billing CPT-4 Codes

           

            Federal Law

           

            Physician Self-Referral

 

            Government Investigations and Advice

 

Errors Relating to Code Linkage and Medical Necessity

 

            Errors Relating to the Coding Process  

Errors Relating to the Billing Process

 

National Correct Coding Initiative (NCCI)

 

Fraudulent Actions and Compliance Errors

 

Compliance

           

            How to be Compliant

 

            Benefits of a Voluntary Compliance Program

 

Ethics for the Medical Coder

   

CHAPTER 8: AUDITING

 

Auditing

 

External Audit

 

Internal Audit

 

Purpose of an Audit

 

Private Payer Regulations

 

Medical Necessity for E/M Services

 

Audit Tool

 

Key Elements of Service  

History

 

           

Examination

 

            Medical Decision Making

                       

Tips for Preventing Coding Errors with Specific E/M Codes  

 

Section IV: Medical Claims

 

 

CHAPTER 9: PHYSICIAN MEDICAL BILLING

 

Patient Information

 

Superbills

 

Types of Insurance Claims

 

Optical Character Recognition

 

CMS — 1500 Form

 

Physicians’ Identification Numbers

 

Common Reasons why CMS-1500 Claim Forms are Delayed or Rejected

 

HIPAA Compliance Alert

 

Filing Secondary Claims

 

Determining Primary Coverage

 

 

CHAPTER 10: HOSPITAL MEDICAL BILLING

 

 

Inpatient Billing Process

 

Charge Description Master

 

Types of Payers

 

Coding and Reimbursement Methods

 

Diagnosis Related Group System (DRG)

 

Cost Outliers

 

ICD-9CM Procedural Coding

 

Hospital Billing Claim Form (UB-04)

 

Instructions for Completing UB-04

 

Codes for UB-04

 

            Sex Codes

 

            Admission Codes

 

            Discharge Codes

 

            Condition Codes

 

            Occurrence Code Examples (Form Locater 31-34)

           

            Value Codes

 

            Revenue Codes

 

            Patient Relationship

 

             

Section V: Government Medical Billing

 

 

CHAPTER 11: MEDICARE MEDICAL BILLING

 

Medicare History  

Medicare Administration

 

Medicare Intermediary- Part A

 

Medicare Carrier— Part B

 

Claim Processing: Medicare Part A Provider- Intermediary

           

            Inpatient Hospital Care

 

Skilled Nursing Facility

 

Home Health Care

 

Hospice Care

 

Inpatient Benefit Days

 

Basic Days

 

Co-Insurance Days

 

Lifetime Reserve Days (LTR)

 

Skilled Nursing Facility

 

Hospice Care

 

Claims Processing: Medicare Part B- Carrier

 

Medicare Part C

 

Medicare Part D

           

            Services Not Covered by Medicare Part A and Part B

 

Requirements for Medical Necessity

 

Fee-for-Service: The Original Medicare Plan

 

Medicare Advantage Plus or Medicare Part C

 

Medicare Coverage and Eligibility

 

Medicare Providers

 

Part A Providers

           

Part B Providers

 

Participating vs. Non-participating

 

Limiting Charge

 

            Determining the Medicare Fee and Limiting Charge

 

Patient Registration

 

Copying the Medicare Card  

Obtaining Patient Signatures

 

Determining Primary or Secondary Payer  

Plans Primary to Medicare

 

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

           

            Disabled

           

            End-stage Renal Disease (ESRD)

 

            Workers’ Compensation

           

            Automobile, No-Fault and Liability Insurance

Veteran Benefits

 

Medicare Coordination of Benefits Contractor (COB)

 

            Hospital Registration

 

            Medicare as the Secondary Payer

 

Medigap, Medicaid and Supplemental Insurance

 

Conditional Payment

 

Medicare Documents

 

Development Letter

 

Medicare Insurance Billing Requirements

 

HCPCS

 

Completing Medicare Part B Claims

  Form Locators for Medicare Part B Claims

 

Railroad Retirement

O MEDICARE

Local Coverage Determination (LCD)

 

Medicare Remittance Notice

 

CMS-1500 FORM — Form Locator 29

Determining Medicare Fraud and Abuse

 

Common types of Medicare abuse

 

 

CHAPTER 12: MEDICAID

 

Medicaid Guidelines

 

Eligibility Groups

 

            Categorically Needy

 

            Medically Needy

 

Immigrants

 

TANF

 

State Children’s Health Insurance Program (SCHIP or CHIP)

 

Scope of Medicaid Services

 

PACE

 

Amount and Duration of Medicaid Services

 

Payment for Medicaid SErvices

 

Medicaid Summary and Trends

 

The Medicaid- Medicare Relationship (Medi-Medi)

 

Medicaid Managed Care

 

Medicaid Verification

 

Medicaid Claims Filing

 

Time Limits for Submitting Claims

 

Exceptions to the 95-Day Filing Deadline 

 

Appeal Time Limits

 

Claims with Incomplete Information and Zero Paid Claims  

Newborn Claim Hints

 

Completing the CMS-1500 for Medicaid (Primary)

 

 

 

CHAPTER 13: TRICARE

Tricare

            Fiscal Year             Authorized Providers

 

            Preauthorization Tricare Standard

            Non-availability statement (NAS)

Tricare Prime

Tricare Prime Remote (TPR)

Tricare EXTRA

Tricare Senior Prime Tricare for Life

CHAMPVA

Submitting Claims to Tricare

Completing the CMS-1500 for Tricare (Primary)

            Timely Filing

Confidential and Sensitive Information

            Penalties and Interest Charges

 

Section VI: Accounts Receivable

CHAPTER 14: EXPLANATION OF BENEFITS AND PAYMENT ADJUDICATION

Steps for Filing a Medical Claim

Claim Process

            Adjudication

Determining the Fees

            Charge-based fee structures

Resource-based fee structures

History of the RBRVS

Resource Based Relative Value Scale (RBRVS)

Determining the Medicare Fee

Allowed Charge

Payers Policies

Capitation

Calculations of Patient Charges

            Deductible

            Copayments

            Coinsurance

            Excluded Services

Balance Billing

Processing an EOB

            Information On An EOB Using Claims Information

 

Adjustments to Patient Accounts

            Processing Reimbursement Information Determining the Amount Paid/Adjustments/Patient Due

Methods of Receiving Funds

            Check by Mail

            Electronic Funds Transfer (EFT)

            Lock Box Services  

CHAPTER 15: REFUNDS AND APPEALS

Reimbursement Follow-up

Rebilling

Denied or Delayed Payments

Answering Patients’ Questions about Claims

Claim Rejection Appeal

Peer Review State Insurance Commissioner Carrier Audits Documentation

 

SOAP (Format of Record Keeping)

 

Documentation Guidelines

 

Registering a Formal Appeal

 

            Reason Codes That Require A Formal Appeal

The Employee Retirement Income Security Act of 1974(ERISA)

            Waiting Period For An ERISA Claim

            Appeal to ERISA

Medicare Appeals

            Redetermination

            Second Level of Appeal

            Third Level of Appeal and Beyond

Necessity of Appeal

            Closing Words

Appealing Denied Claims             Do Not Settle for “Denial Upheld”

 

Refund Guidelines

            Avoid Excessive Overpayments

            Guide to Insurance Overpayments and Refund Requests.

 

Section VII: Injured Employee Medical Claim

CHAPTER 16: WORKERS’ COMPENSATION

History of Workers’ Compensation

Federal Workers’ Compensation Programs

           

State Workers’ Compensation Plans

Overview of Covered Injuries, Illness, and Benefits

            Occupational Diseases

            Work-Related Injury Classifications

Injured Worker Responsibilities and Rights

Treating Doctor’s Responsibilities

            Selecting a Designated Doctor and Scheduling an Appointment

            Communicating With the Designated Doctor

What the Designated Doctor Will Do

Disputing the Designated Doctor's Findings

Maximum Medical Improvement and Impairment

Disputing Maximum Medical Improvement or Impairment Rating

Ombudsmen

Types of Workers’ Compensation Benefits

            Medical Benefits

            Income Benefits

            Death and Burial Benefits

Eligible Beneficiaries

Dependent Child, Grandchild, and Other Eligible Parties

Benefits and Compensation Termination

Disability Compensation Programs

            Types of Government Disability Policies

Verifying Insurance Benefits

Preauthorization

            Requirements For The Preauthorization Request

Filing Insurance Claims

Completing the CMS-1500 for Workers’ Compensation Claims

Independent Review Organizations

            How to Obtain an Independent Review

            The IRO Decision

Medical Records

Fraud

            Penalties

            Medical Provider Fraud

Calculate Reimbursement

Section VIII: Computer Application

CHAPTER 17: MEDICAL CLAIMS PROCESSING

Simulation Instructions

            Tips for Entering Information into Medical Practice Management (MPM) Software

 

Appendix A:     Completing the CMS-1500 Form (08/05): Case Studies

Appendix B:     Completing the CMS-1500 Form and Determining the Diagnostic Code: Case Studies

Appendix C: Medical Forms

Appendix D: Completing the UB-04 Form: Case Studies

Appendix E: Abbreviations

Appendix F: Medical Terminology Word Parts

Appendix G: Helpful Websites

Appendix H: HIPAA Regulations

Appendix I: Payment Posting Using Advanced NDC Medisoft (v. 12)

Glossary

Bibliography