Generate patient statements. Monitor payer adjudication

Transcription

1 Preface Follow the Money! Medical insurance plays an important role in the financial well-being of every health care business. The regulatory environment of medical insurance is evolving faster than ever. Changes due to health care reform require medical office professionals to acquire and maintain an in-depth understanding of compliance, electronic health records, medical coding, and more. The fifth edition of Medical Insurance: An Integrated Claims Process Approach emphasizes the medical billing cycle ten steps that clearly identify all the components needed to successfully manage the medical insurance claims process. The cycle shows how administrative medical professionals follow the money. Medical insurance specialists must be familiar with the rules and guidelines of each health plan in order to submit proper documentation. This ensures that offices receive maximum, appropriate reimbursement for services provided. Without an effective administrative staff, a medical office would have no cash flow! Here are some of the key skills covered for you and your students in Medical Insurance, 5e : Step 9 Step 8 Generate patient statements Step 10 Monitor payer adjudication Follow up payments and collections Prepare and transmit claims Step 7 Step 1 Preregister patients Check billing compliance Step 2 Medical Billing Cycle Step 6 Establish financial responsibility Review coding compliance Step 5 Check-in patients Check-out patients Step 3 Step 4 Procedural skills Communication skills Health information management skills Medical coding skills HIPAA/HITECH skills Learning administrative duties important in medical practices, as well as how to bill both payers and patients. Working with physicians, patients, payers, and others, using both written and oral communication. Using practice management programs and electronic health records technology to manage both patient records and the billing/collections process, to electronically transmit claims, and to conduct research. Understanding the ICD-9, ICD-10, CPT, and HCPCS codes and their importance to correctly reporting patients conditions on health insurance claims and encounter forms, as well as the role medical coding plays in the claims submission process. Applying the rules of HIPAA (Health Insurance Portability and Accountability Act) and HITECH (Health Information Technology for Economic and Clinical Health act) to ensure compliance, maximum reimbursement, and the electronic exchange of health information. xi

2 About the Cover In putting together our cover image, we wanted to represent the medical billing cycle, while highlighting the theme of follow the money. You can see the evolution from sketch to final cover in the images below. Here s How Your Colleagues Have Described Medical Insurance: For students to gain a better understanding of the material and gain the skills required to work in medical insurance, billing, and coding, they need to have a sound foundation of the nuances, guidelines, and requirements involved. This approach provides the students with the foundational blocks first, and then systematically builds on them. Cynthia Greiner Holmes, MAM The Valerius text is just right. It covers a difficult topic, but is laid out in such a way that if a person is learning the material for the first time, he or she can easily follow along. If an individual already knows some of the material, the chapters are laid out and labeled in such a way that he or she can easily, without confusion, continue on to the next topic without losing the way. Georgina Sampson, RHIA, Anoka Technical College This is the perfect textbook for teaching students the fundamentals of insurance, coding, billing/follow-up along with HIPAA compliance guidelines. Kimberly K. Rash, Gateway Community and Technical College This text is an excellent tool to prepare students to work in the physician practice. It gets straight to the point and provides students with all the information they need to get started. Nikita Carr, CPC, CMBS, Centura College A comprehensive text with thorough, yet easy to follow content not overwhelming for basic/introductory insurance, coding, and billing courses. Denise Kearney, CPC, Wayne Community College xii Preface

3 Organization of Medical Insurance, 5e Part Coverage 1: Working with Medical Insurance and Billing Covers Steps 1 through 4 of the medical billing cycle by introducing the major types of medical insurance, payers, and regulators, as well as the medical billing cycle. Also covers HIPAA Privacy, Security, and Electronic Healthcare Transactions/Code Sets rules. 2: Claim Coding Covers Steps 5 and 6 of the medical billing cycle, while building skills in correct coding procedures, use of coding references, and compliance with proper linkage guidelines. 3: Claims Covers Step 7 of the medical billing cycle by covering the general procedures for calculating reimbursement, how to bill compliantly, and preparing and transmitting claims. 4: Claim Follow-up and Payment Processing Covers Steps 8 through 10 of the medical billing cycle by providing descriptions of the major third-party private and governmentsponsored payers procedures and regulations, along with specific filing guidelines. Also explains how to handle payments from payers, follow up and appeal claims, file secondary claims, and correctly bill and collect from patients. This part includes two case studies chapters that provide exercises to reinforce knowledge of completing primary/secondary claims, processing payments from payers, and handling patients accounts. These case studies can be completed using Medisoft Advanced Version 16. 5: Hospital Services Provides necessary background in hospital billing, coding, and payment methods. Guide to Medisoft and Guide to Interactive Simulated CMS-1500 Form Provides information on how to work with Medisoft and the interactive CMS-1500 form. The text reads like a set of directions that are easy to follow and understand. The inclusion of many forms/documents and diagrams provide visual examples further emphasizing the topic. Ja n e W. D u m a s, CCM A, CPT, CET, CH I, R e ming to n College New to the Fifth Edition One of the first things you may notice, if you are familiar with earlier editions, is that the design of Medical Insurance has been updated and refreshed. Medical Insurance is now designed around the medical billing cycle, with each part of the book dedicated to a section of the cycle, followed by case studies to apply the skills needed in each section. The addition of end-of-chapter summaries allows for easier review. Key content changes include: Pedagogy Learning Outcomes are restated to reflect the revised version of Bloom s Taxonomy. Major chapter heads are structured to reflect the numbered Learning Outcomes. Thinking It Through questions have been added to assess each Learning Outcome. Preface xiii

4 End-of-chapter elements are now tagged with Learning Outcomes. New Chapter Summaries have been created in a tabular, step-by-step format with page references. Revised chapter structure lets students progress through the complete medical billing cycle, including the Primary Case Studies and the RA/ EOB/Secondary Case Studies. This new structure is reinforced by the design that ties the medical billing cycle clearly to the chapter. HIPAA-Related Updates 2011 ICD-9-CM and CPT/HCPCS codes are now included. HITECH rules are incorporated. Tips are now titled HIPAA/HITECH. Chapter by Chapter Chapter 1: New key terms certification, Patient Protection and Affordable Care Act (PPACA); updated Figure 1.1 reflects current employment statistics; chapter now emphasizes the importance of certification for career advancement Chapter 2: HITECH concepts added; new key terms American Recovery and Reinvestment Act, breach, breach notification, HITECH Chapter 3: New key terms cash flow, revenue cycle management, realtime benefit information; Internet-based insurance verification procedures added; new emphasis on real-time claim adjudication and time of service (TOS) collections Chapter 4: New key term ICD-10-CM; expanded introduction to ICD-10-CM with Thinking It Through to practice locating codes using the Internet-based code set Chapter 5: New key term resequenced; new topic of CPT resequenced codes Chapter 6: New key terms Certificate of Medical Necessity (CMN), never events, Pricing, Coding Analysis, and Coding (PDAC) contractor, Durable Medical Equipment Medicare Administrative Contractor (DME MAC); updated HPCPS contractor information Chapter 7: New key term Recovery Audit Contractor (RAC) Chapter 8: New billing tip on acceptable provider signatures Chapter 9: New key term medical home model; concept of medical home model introduced; new coverage of out-of-network billing and fees the FAIR Health Inc. out-of-network physician payment database Chapter 10: New discussion on voluntary use of ABN (replacing the NEMB); step-by-step instructions on filling out the ABN; discussion of nonpayment of CPT consultation codes under the Medicare Physician Fee Schedule; effect of the Health Reform Act (PPACA) on Medicare claims (now 12 months is the deadline by which providers may submit Medicare Claims) Chapter 11: New concept and key term Medicaid Integrity Program (MIP) Chapter 14: Update for Medicare Appeals Process and FERA rule Chapter 15: New key terms Red Flag rule, Equal Credit Opportunity Act (ECOA) Chapters 16 and 17: Updated for Medisoft Advanced Version 16 xiv Preface

5 Chapter 18: New coverage of hospital-acquired conditions (HACs) as they relate to never events; new never events modifiers; more information on MS-DRGs, new UB-04 claim exercises; updated coverage of the RAC program; explanation of ICD-10-PCS; new key terms hospital-acquired condition (HAC), major diagnostic category (MDC), hospital-issued notice of noncoverage (HINN), ICD-10-PCS To the Instructor McGraw-Hill knows how much effort it takes to prepare for a new course. Through focus groups, symposia, reviews, and conversations with instructors like you, we have gathered information about what materials you need in order to facilitate successful courses. We are committed to provide you with high-quality, accurate instructor support. Using Medisoft Advanced Version 16 with Medical Insurance Medical Insurance features Medisoft Advanced Version 16 patient accounting software with Chapters 16 and 17. McGraw-Hill has partnered with Medisoft from the very beginning, going back fifteen years to when the software was DOS-based! The support you receive when you are using a McGraw-Hill text with Medisoft is second to none. Your students will need the following: Minimum System Requirements Pentium III 500 MHz (minimum) or higher processor 500 MB available hard disk space 512 MB RAM 32-bit color display (minimum screen display of ) Windows XP Professional SP3 or higher 32-bit Windows Vista Business SP1 or higher 32-bit Windows 7 Ultimate External storage device, such as a USB flash drive, for storing backup copies of the working database Medisoft Advanced Version 16 patient billing software Student data file, available for download from the book s Online Learning Center, Instructor s Software: Medisoft Advanced Version 16 CD-ROM Instructors who use McGraw-Hill Medisoft-compatible titles in their courses receive a fully working version of Medisoft Advanced Version 16 software, which allows a school to place the live software on the laboratory or classroom machines. Only one copy is needed per campus location. Your McGraw-Hill sales representative will help you obtain Medisoft for your campus. Preface xv

6 Medisoft-Compatible Titles Available from McGraw-Hill: Sanderson, Computers in the Medical Office (CiMO), 7e , Sanderson, Case Studies for Use with Computers in the Medical Office, 6e X, Valerius/Bayes/Newby/Seggern, Medical Insurance: An Integrated Claims Process Approach, 5e , Valerius/Bayes/Newby/Seggern, Workbook for Use with Medical Insurance: An Integrated Claims Process Approach, 5e , Bayes/Crist/Becklin, Medical Office Procedures, 7e , xvi Preface

7 The McGraw-Hill Guide to Success for Medisoft Advanced Version 16 We want your transition to Medisoft Advanced Version 16 to be a snap! In The McGraw-Hill Guide to Success for Medisoft Advanced Version 16, the following topics are addressed: Software installation procedures for both the Instructor Version and the Student At-Home Version of Medisoft Student data files installation procedures Use of flash drives Backup and restore processes Frequently asked questions (FAQs) Instructor resources Technical support Ask your McGraw-Hill sales representative to send you a copy, or visit to review the materials online. Instructor Resources You can rely on the following materials to help you and your students work through the exercises in the book: Instructor Edition of the Online Learning Center at valerius5e. Your McGraw-Hill sales representative can provide you with access and show you how to go green with our online instructor support. Instructor s Manual with course overview; lesson plans; sample syllabi; transition guides; answer keys for end-of-chapter questions; and correlations to competencies from several organizations such as ABHES, CAAHEP, and CAHIIM. More details can be found in the IM and at the book s website, A PowerPoint slide presentation for each chapter, containing teaching notes correlated to Learning Outcomes. Each presentation seeks to reinforce key concepts and provide a visual for students. The slides are excellent for in-class lectures. Test bank and answer key for use in classroom assessment. The comprehensive test bank includes a variety of question types, with each question linked directly to its Learning Outcome, Bloom s Taxonomy, and difficulty level. Both a Word version and a computerized version (EZ Test) of the test bank are provided. Conversion Guide with a chapter-by-chapter breakdown of how the content has been revised between editions. The guide is helpful if you are currently using Medical Insurance and moving to the new edition, or if you are a first-time adopter. Instructor Asset Map to help you find the teaching material you need with a click of the mouse. These online chapter tables are organized by Learning Outcomes, and allow you to find instructor notes, PowerPoint slides, and even test bank suggestions with ease! The Asset Map is a completely integrated tool designed to help you plan and instruct your courses efficiently and comprehensively. It labels and organizes course material for use in a multitude of learning applications. Preface xvii

8 Connect Plus : McGraw-Hill Connect Plus is a revolutionary online assignment and assessment solution, providing instructors and students with tools and resources to maximize their success. Through Connect Plus, instructors enjoy simplified course setup and assignment creation. Robust, media-rich tools and activities, all tied to the textbook Learning Outcomes, ensure you ll create classes geared toward achievement. You ll have more time with your students and spend less time agonizing over course planning. McGraw-Hill LearnSmart for Medical Insurance, Billing, and Coding: LearnSmart diagnoses students skill levels to determine what they re good at and where they need help. Then, it delivers customized learning content based on their strengths and weakness. The result: Students get the help they need, right when they need it instead of getting stuck on lessons, or being continually frustrated with stalled progress. McGraw-Hill Higher Education and Blackboard have teamed up. What does this mean for you? 1. Your life, simplified. Now you and your students can access McGraw-Hill s Connect and Create right from within your Blackboard course all with one single sign-on. Say goodbye to the days of logging in to multiple applications. 2. Deep integration of content and tools. Not only do you get single sign-on with Connect and Create, you also get deep integration of McGraw-Hill content and content engines right in Blackboard. Whether you re choosing a book for your course or building Connect assignments, all the tools you need are right where you want them inside of Blackboard. 3. Seamless gradebooks. Are you tired of keeping multiple gradebooks and manually synchronizing grades into Blackboard? We thought so. When a student completes an integrated Connect assignment, the grade for that assignment automatically (and instantly) feeds your Blackboard grade center. 4. A solution for everyone. Whether your institution is already using Blackboard or you just want to try Blackboard on your own, we have a solution for you. McGraw-Hill and Blackboard can now offer you easy access to industry leading technology and content, whether your campus hosts it, or we do. Be sure to ask your local McGraw-Hill representative for details. Need Help? Contact the Digital Care Support Team Visit our Digital CARE Support website at Browse the FAQs (frequently asked questions) and product documentation, and/or contact a CARE support representative. The Digital CARE Support Team is available Sunday through Friday. xviii Preface

9 Beyond Medical Insurance: Opportunities for Your Students to Apply their Skills Workbook for Use with Medical Insurance: An Integrated Claims Process Approach, Fifth Edition ( , ) The Workbook for Use with Medical Insurance has excellent material for reinforcing the text content, applying concepts, and extending understanding. It combines the best features of a workbook and a study guide. Each workbook chapter enhances the text s strong pedagogy through: Assisted Outlining reinforce the chapter s key points Key Terms objective questions and crossword puzzles/word finds Critical Thinking questions that stimulate process understanding Guided Web Activities build skill in locating and then evaluating information on the Internet Applying Concepts reinforce and extend abstracting insurance information, calculating insurance math, and using insurance terms The workbook matches the text chapter-by-chapter. It reinforces, applies, and extends the text to enhance the learning process. Medical Coding Workbook for Physician Practices & Facilities Edition ( , ) The Medical Coding Workbook provides practice and instruction in coding and compliance skills. Since medical insurance specialists verify diagnosis and procedure codes and use them to report physicians services, a fundamental understanding of coding principles and guidelines is the baseline for correct claims. The coding workbook reinforces and enhances skill development by applying the coding principles introduced in Medical Insurance, 5e and extending knowledge through additional coding guidelines, examples, and compliance tips. It offers over 75 case studies that simulate more real-world application. Also included are inpatient scenarios for coding that require compliance with ICD-9-CM Official Guidelines for Coding and Reporting sequencing rules, as explained in Chapter 18 of the text. Preface xix

10 CodeitRightOnline : Your Online Coding Tool So that your students can gain experience with the use of an online coding tool, they will have access for a 14-day period to CodeitRightOnline, produced by Contexo Media, a division of Access Intelligence. Features These are the general features that are offered with a subscription: CodeitRightOnline Search The ability to find a CPT, HCPCS Level II, and ICD-9-CM code either using the Index or Tabular search sections, by code terminology, description, keyword, or code number to locate the correct code. Plus, the Single Search Feature allows you to locate all codes related to a particular term. Fully customizable Provides note capability, LCD customization, personalized searches and fee schedules, and specialty-specific code sets. Print Custom Coding Books Subscribers can create and print their own specialty-specific CPT, HCPCS, ICD-9-CM, and RVU books. Coding Crosswalks Essential coding links from CPT codes to ICD-9-CM to HCPCS Level II codes and to Anesthesia codes. Articles We have compiled articles from CMS, OIG, carriers, intermediaries, payers, and other government websites along with newsletter articles from AMA, AHA, Decision Health, Coding Institute, and others. Plus LCD/NCD codes for a local state carrier, Medicare s payment policy indicators, and, of course, CPT, HCPCS Level II, and ICD-9-CM codes with full descriptions and our Plain English Definitions. ICD-10-CM/PCS Code Sets Helps you prepare for 2013 mandatory implementation with ICD-10-CM/PCS full code sets and descriptions. NCCI Edits Validator Validates codes to help you remain in compliance with the correct coding guidelines established by the Centers for Medicare & Medicaid Services (CMS). Automatic Updates Ensures that CodeitRightOnline contains the most up-to-date, real-time information. Build-A-Code Allows students to build codes from the ground up, helping them understand how ICD-10 codes are constructed. Click-A-Dex Helps index searches for easy future reference. Comprehensive Medicare Resource Contains local coverage determination (LCD) and national coverage determination (NCD) information, contact information for comprehensive list of Medicare providers, and information on how to bill for procedures allowed by Medicare s Physician Quality Reporting Initiative (PQRI) program. ABC Codes and Descriptions Provide access to the alternative medicine codes you need to describe services, remedies, and/or supplies required during patient visits. xx Preface

11 Using the Online Coding Tool Go to CodeitRightOnline to complete the steps needed to begin. The following screen will appear: Click on the Free Trial tab at the top right-hand corner of the screen. On the page that appears, enter your name, address, school, phone, and address. Next, click on Use account contact information for your account administrator information, a one-time process that optimizes CodeitRight- Online for your particular location. Choose a username and password you will remember. Next, read the Terms and Conditions, including the AMA Agreement. After accepting these Terms and Conditions, click Continue. You will then receive an containing an activation link. Clicking on the link will activate your account. From that page, follow the Click here link to sign in with the account information you selected. This will take you to the CodeitRightOnline home page you re in! These actions set up your trial subscription. Now, to use the online coding tool to locate codes, click Search and select the appropriate code set. Next, choose the start point for your code search. For example, select ICD-9-CM Vol 1,2 and Vol 3 in the Show Results For box, enter the term fracture, and click Search. CodeitRightOnline will return a list of the various fracture entries for your selection. To see how it works, choose Fracture of Ribs, Closed and click the code number to review the Tabular List entry. Preface xxi