WEEK CHAPTER OBJECTIVES ASSIGNMENTS & TESTS A medical necessity as it ICD-9-CM Coding. relates to reporting diagnosis codes on claims.

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1 HEALTH INSURANCE & CODING Textbook: Understanding Health Insurance: A Guide to Billing and Reimbursement 11 th edition Website Activities: StudyWARE Online Practice Software linked to the book. SimClam: Online Practice Software to complete CMS-1500 forms. WEEK CHAPTER OBJECTIVES ASSIGNMENTS & TESTS A o Explain the concept of Read pp medical necessity as it ICD-9-CM Coding relates to reporting diagnosis codes on Complete exercises 6A-1 through 6A-12. o List and apply CMS outpatient guidelines when coding diagnoses. o Identify and properly use ICD-9-CM s coding conventions. o Accurately code diagnoses Complete coding exercises according to ICD-9-CM. at the end of the chapter. o Explain the differences Complete worksheet between ICD-9_CM and handout on coding. ICD-10CM/PCS **Test 6A Written Test 21 7 CPT Coding o Explain the format used in CPT. o Locate main terms and subterms in the CPT index. o Select appropriate modifiers to add to CPT codes. o Assign CPT codes to procedures and services. Read pp Complete exercises Complete exercises at the end of the chapter. Complete worksheet handout on CPT coding. Health Insurance & Medical Coding Page 1

2 HCPCS Level II Coding Legal and Regulatory Issues o Describe the HCPCS levels. o Assign HCPCS level II codes and modifiers. o Identify claims to be submitted to Medicare administrative contractors according to HCPCS level II code numbers. o List situations in which both HCPCS levels I and II codes are assigned. o Provide examples of a statute, regulation, and case law, and explain the use of the Federal Register. o Summarize federal legislation and regulations affecting health care. o Explain retention of records laws o List and explain HIPAA s provisions. **Test 7 Written Test Read pp Read pp Managed Health Care o Discuss the history of managed care in the United States. o Explain the role of a managed care organization. o Describe six managed care models, and provide details about each. o List and define consumerdirected health plans. o Identify the organization that accredits managed care organizations. o Describe the effects of managed care on a physician s practice o Describe the processing of an insurance claim. Read pp Read pp Health Insurance & Medical Coding Page 2

3 26 11 Processing an Insurance Claim Essential CMS-1500 Claim Instructions o Explain how claim processing for new and established patients differs. o Manage the office s insurance finances. o Discuss the life cycle of an insurance claim, including electronic data interchange (EDI). o Maintain a medical practice s insurance claim files. o Explain the role of credit and collections in processing o List and define general insurance billing guidelines. o Apply optical scanning guidelines when completing o Enter patient and policyholder names, provider names, mailing addresses, and telephone numbers according to claims completion guidelines. o Describe how funds are recovered from responsible payers. o Explain the use of the national provider identifier (NPI). o Differentiate between assignment of benefits and accept assignment. o Report ICD-9-CM, ICD-10- CM, HCPCS level II, and CPT codes according to claims completion guidelines. o Explain the use of the national standard employer identifier. o Explain when the signature of a physician or supplier is required on a claim. o Enter the filling entity according to claims completion guidelines. o Explain how secondary Read pp Health Insurance & Medical Coding Page 3

4 27 12 Commercial Insurance claims are processed. o List and describe common errors that delay claims processing. o State the final steps required in claims processing. o Establish insurance claim files for a physician s practice. o Explain the characteristics of commercial insurance plans. o Differentiate among automobile, disability, and liability insurance. o Differentiate between primary and secondary commercial o Complete commercial primary and secondary feefor-service Read pp Blue Cross o Explain the history of Blue Cross and Blue Shield. o Differentiate among Blue Cross/Blue Shield plans. o Apply blue Cross Blue Shield billing notes when completing CMS-1500 o Complete Blue Cross Blue Shield primary and secondary Read pp o Explain Medicare eligibility guidelines Read pp Health Insurance & Medical Coding Page 4

5 30 15 Medicare Medicaid o Describe the Medicare enrollment process. o Differentiate among Medicare Part A, Part B, Part C, and Part D Coverage. o Define other Medicare health plans, employer and union health plans, Medigap, and private contracting. o Calculate Medicare reimbursement amount for participating and nonparticipating providers. o Explain Medicaid eligibility guidelines. o List Medicaid-covered services required by the federal government. o Describe how payments for Medicaid services are processed. o Apply Medicaid billing notes when completing CMS-1500 o Complete Medicaid primary, secondary, mother/baby, and SCHIP Read pp TRICARE o Explain the historical Read pp background of TRICARE. o Describe how TRICARE is administered. o Define CHAMPVA. o List and explain the TRICARE options, programs and demonstration projects, and supplemental plans. o Apply TRICARE billing notes when completing CMX-1500 o Complete TRICARE Health Insurance & Medical Coding Page 5

6 claims properly Workers Compensation o Describe federal and state workers compensation programs. o List eligibility requirements for workers compensation coverage. o Classify workers compensation cases. o Describe special handling practices for workers compensation cases. o Explain how managed care applies to workers compensation coverage. o Submit first report of injury and progress reports. o Describe workers compensation appeals and adjudication processes. o State examples of workers compensation fraud and abuse. o Apply workers compensation fraud and abuse. o Apply workers compensation billing notes when completing CMS o Complete workers compensation claims properly. Read pp Health Insurance & Medical Coding Page 6