Medical billing and coding demystified

305 Pages·2016·26.05 MB·English

by  Burgos

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Medical Billing and Coding 5
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Medical Billing 5
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Second Edition ill G
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Marilyn Burgos, BSBA s, L
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Donya P. Johnson, BS . N
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Jim Keogh RN-BC, MSN be
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With contributions by Marissa Hernandez istrib
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I want to thank God for allowing me the privilege and opportunity to be a coauthor for 56
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this book. Thank you Jim for working diligently and patiently with us—it has been a ] a
wonderful experience. To all my mentors in the medical field, thank you for your insight, t [07
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support, and guidance which has helped shape me into the healthcare professional I am /1
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today. For my beautiful daughter Emilie Rose, who has always been my enthusiastic ]. C
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supporter; may you grow up and stay as enthusiastic in all that you set your mind to. rig
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Those who say it cannot be done should not interrupt the person doing it. t ©
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—Marilyn Burgos, BSBA ra
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I would have fainted had I failed to see the goodness of God. ill G
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Thank You Glenn, Dianne, and Jonathan for all of your love and support. a
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—Donya P. Johnson, BS ca
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This book is dedicated to Anne, Sandy, Joanne, Amber-Leigh Christine, Shawn, Eric, ld
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and Amy. Without their help and support, this book couldn’t have been written. s, L
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—Jim Keogh, RN-BC, MSN . N
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Contents .6
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Introduction xi /1
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CHAPTER 1 Introduction to Medical Billing and Coding 1 t © M
1. The Business of Healthcare 2 cG
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2. The Economics of Healthcare 3 w-H
3. The Money Game 7 ill G
4. The Marketing Game 9 lob
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5. A Brief Look Back at Healthcare 10 l E
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6. Medical Insurance Specialist 18 ca
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CHAPTER 2 Ethical and Legal Aspects of Medical Billing 25 o
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1. Insight Into Medical Billing 26 ing
2. Ethics and Medical Billing 26 s, LL
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3. Legal Aspects of Medical Billing 29 . N
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4. Civil Law 30 t to
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5. Contracts 33 e re
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67.. TTyhpee Fse oafs aCnivciel sL aw 3357 istribu
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8. The Four Ds of Negligence 38 o
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9. Types of Criminal Law 39 o
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10. Confidentiality 40 ifie
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viii CoNTENTS D
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CHAPTER 3 Medical Terminology and Procedures 47 ed
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1. Insight Into Medical Terminology [ F
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and Procedures 48 cu
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2. The Secret to Understanding o
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Medical Language 48 u
3. Mastering Medical Terminology 50 rsing
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4. Medical Tests, Procedures, and Treatments 53 h
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CHAPTER 4 Medical Office Procedures 69 a
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1. Behind the Scenes 70 niv
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2. The Healthcare Team 74 rsity
3. Medical office Procedures 77 5.6
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4. Telephone Calls 79 .1
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5. The Answering Service 83 .86
6. Making Calls on Behalf of ] at [0
the Medical Practice 84 7/1
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7. Medical Records 84 /16
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CHAPTER 5 Introduction to Procedural Coding 91 py
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1. Here’s How Coding Works 92 ht ©
2. Getting Paid 93 M
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3. The Healthcare Common Procedure ra
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Coding System 94 -H
4. Current Procedural Terminology 94 ill G
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5. Inside the CPT Manual 95 ba
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6. Level II National Codes 96 d
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7. ICD-10-CM 98 atio
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8. Hands-on Coding 102 H
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CHAPTER 6 Introduction to Insurance Plans 107 gs, L
1. What Is Insurance? 108 L
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2. Sharing Risk 109 . N
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3. How Insurers Make Money 110 t to b
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4. How Practitioners Make Money 111 re
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5. Healthcare Financing 112 istrib
6. Health Insurance Premium 113 ute
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7. Medical Coverage 115 or m
8. Assessing the Value of a Healthcare Policy 115 od
9. Types of Healthcare Plans 116 ified
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10. Types of Indemnity Insurance 117 a
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11. Types of Managed Care Plans 118 w
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12. Health Savings Accounts 120 w
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CoNTENTS ix D
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13. Auto Insurance and Healthcare 120 ed
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14. Disability Insurance 120 [ F
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15. Workers’ Compensation 121 cu
16. Liability Insurance and Healthcare 121 lty o
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CHAPTER 7 The Insurance Claim Cycle 125 rsin
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1. Inside the Insurance Claim Cycle 126 , C
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2. Verify Insurance Information 128 ian
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3. Input Patient Information 129 a
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4. Create an Encounter Form 130 n
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5. Calculate Medical Fees 132 rsity
6. Preparing the Claim 133 5
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7. Send the Claim 133 .1
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8. The Claim Is Received 134 .8
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9. The Insurance Claim 135 ] at [0
10. HIPAA Claims and Paper Claims 140 7/1
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11. Health Insurance Portability /16
and Accounting Act 142 ]. C
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12. Types of Health Insurance Coverage 142 yrig
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CHAPTER 8 Billing and Coding Errors: How to Avoid Them 153 M
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1. The Hidden Cost of Errors 154 Gra
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2. Types of Errors 156 -H
3. Dumb Mistakes 157 ill G
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4. Red Flags 158 b
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5. The Penalty for Coding Errors 159 d
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CHAPTER 9 Strategies for Handling Claim Disputes 163 tion
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1. The Claim Adjudication Process 164 old
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2. The Medical Review Department 165 gs, L
3. Remittance Advice Confusion 168 L
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4. Explanation of Benefits Confusion 169 . N
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5. Reviewing a Remittance Advice 169 t to
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6. Handling Exceptions 170 re
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CHAPTER 10 Medical Transportation 179 istribu
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1. Transporting Patients 180 d o
2. Vehicle and Crew Requirements 181 r mo
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3. Reasonableness and Medical Necessity 181 ifie
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4. Ambulance Condition Codes 182 in
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5. Basic Life Support and Advanced Life y w
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Support Transportation 183 y
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6. Selecting the Correct Condition Code 184 ith
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7. Transport Indicators 187 t p
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