Accurate processing of health insurance claims has become more exacting and rigorous as health insurance plan options have rapidly expanded. These changes, combined with modifications in state and federal regulations affecting the health insurance industry, are a constant challenge to healthcare personnel. Those responsible for processing health insurance claims require thorough instruction in all aspects of medical insurance, including plan options, payer requirements, state and federal regulations, abstracting of source documents, accurate completion of claims, and coding of diagnoses and procedures/services. Understanding Health Insurance provides the required information in a clear and comprehensive manner.
The objectives of this text are to:
- 1. Introduce information about major insurance programs and federal healthcare legislation.
- 2. Provide a basic knowledge of national diagnosis and procedure coding systems.
- 3. Simplify the process of completing claims.
This text is designed to be used by college and vocational school programs to train medical assistants, medical insurance specialists, coding and reimbursement specialists, and health information technicians. It can also be used as an in-service training tool for new medical office personnel and independent billing services, or individually by claims processors in the healthcare field who want to develop or enhance their skills.
KEY FEATURES
Major features of this text have been updated and expanded:
- Key terms, section headings, and learning objectives at the beginning of each chapter help to organize the material. They can be used as a self-test for checking comprehension and mastery of chapter content. Boldfaced key terms appear throughout each chapter to help learners master the technical vocabulary associated with claims processing.
- Coding exercises are located within the respective coding chapters: ICD-9-CM Coding, CPT Coding, HCPCS Level II Coding, and Coding for Medical Necessity. Answers to coding exercises are available from your instructor.
- Exercises in Chapters 11–17 help students develop claims completion skills.
- Numerous examples are provided in each chapter to illustrate the correct application of rules and guidelines.
- Notes clarify chapter content, focusing the student’s attention on important concepts. Coding Tips provide practical suggestions for mastering the use of the CPT, HCPCS, and ICD-9-CM coding manuals. HIPAA Alerts draw attention to the impact of this legislation on privacy and security requirements for patient health information.
- End-of-chapter reviews reinforce learning and are in multiple-choice format. Answers to chapter reviews are available from your instructor.
- The practice CD-ROM provided with the text includes SIMClaim and StudyWareTM software, as well as a free trial version of Ingenix’s Encoder Pro software. SIMClaim contains case studies (also found in Appendix I and Appendix II of the textbook) that include billing data and patient histories and allow for data entry on CMS-1500 claims and immediate feedback. The complete SIMClaim Procedure Manual is easily accessed on the CD-ROM and provides complete instructions for working with the software. StudyWareTM helps students learn key terms and concepts presented in each chapter by automating chapter exercises. This allows students to complete the exercises multiple times and receive immediate feedback about correct and incorrect answers. (Instructions for using Encoder Pro, SIMClaim and StudyWare are located at the end of this preface.)
NEW TO THIS EDITION
- Chapter 1: A new section about health insurance career opportunities was added, and the professional credentials section was renamed professionalism. New content was also added about internships, professionalism, and telephone skills.
- Chapter 2: Table 2-1 was renamed “significant events of health care reimbursement,” and its content was revised to include only the most significant events. New sections covering medical documentation and the electronic health record (EHR) were added.
- Chapter 3: A table containing the “history of managed care” was relocated to the online companion. Table 3-1 was renamed “significant managed care federal legislation.”
- Chapter 4: The chapter was renamed “Processing Insurance Claims.” New content about electronic data interchange (EDI) was added.
- Chapter 5: New content was added, such as the Medicare Recovery Audit Contractor (RAC) Program.
- Chapter 6: New chapter sections include an overview of ICD-10-CM and ICD-10-PCS and medical necessity. ICD-9-CM coding guidelines and codes are updated. ICD-10-CM alerts were added throughout the chapter to help faculty and students become familiar with differences between ICD-9-CM and ICD-10-CM coding.
- Chapter 7: CPT coding guidelines and codes are updated.
- Chapter 8: HCPCS level II guidelines and codes are updated.
- Chapter 9: Updated content about reimbursement systems has been added.
- Chapter 11: Content about automobile, disability, and liability was relocated from chapter 2, and ICD-10-CM codes were added. (ICD-9-CM codes are also included.)
- Chapter 12: A new section about completing group health plans CMS-1500 claims has been added.
- Chapter 15: A new section about completing SCHIP claims has been added.
- Chapters 12-17: ICD-10-CM codes were added. (ICD-9-CM codes are also included.)
- Fully updated to include the latest industry guidelines and standards.
- New content about the electronic health record, medical documentation, and electronic data interchange.
- Additional ICD-10-CM and ICD-10-PCS coverage to anticipate the transition in 2013, including an ICD-10-CM Alert! feature that displays ICD-9-CM and ICD-10-CM codes side-by-side.
- SIMClaim practice software has improved functionality in feedback mode, targeted block help with video, and the option to print completed forms to PDF for easy emailing and printing.
- StudyWareTM scenario-based coding cases have been updated and use multimediato enhance coding practice.
ORGANIZATION OF THIS TEXTBOOK
- Chapter outlines, key terms, and end-of-chapter summaries facilitate student learning.
- A Study Checklist at the end of each chapter directs learners to various methods of review, reinforcement, and testing.
- Chapter 1, Health Insurance Specialist Career, contains an easy-to-read table that delineates training requirements for health insurance specialists.
- Chapter 2, Introduction to Health Insurance, contains content about healthcare insurance developments.
- Chapter 3, Managed Health Care, contains content about managed care plans, consumer-directed health plans, health savings accounts, and flexible spending accounts.
- Chapter 4, Processing an Insurance Claim, contains content about managing an office visit for a new or established patient, claims processing steps, and the denials/appeals process.
- Chapter 5, Legal and Regulatory Issues, emphasizes confidentiality of patient information, retention of patient information and health insurance records, the Federal False Claims Act, the Health Insurance Portability and Accountability Act of 1996, and federal laws and events that affect health care.
- Chapter 6, ICD-9-CM Coding, contains coding guidelines and coding rules with examples. The coding conventions for the Index to Diseases and the Tabular List of Diseases are located in tables within the chapter, and examples of coding manual entries are included. The chapter review includes coding exercises, which are organized according to the sections in the ICD-9-CM Tabular List of Diseases.
- Chapter 7, CPT Coding, follows the organization of CPT sections. The chapterreview includes coding exercises organized by CPT section.
- Chapter 8, HCPCS Level II Coding, has been updated to reflect revised codes and descriptions.
- Chapter 9, CMS Reimbursement Methodologies, contains information about reimbursement systems implemented since 1983 (including the Medicare physician fee schedule), hospital revenue cycle management, the chargemaster, and the UB-04 (CMS-1450) claim. (A separate chapter about the UB-04 claim is not included in this textbook. The UB-04 claim is automatically generated upon entry of chargemaster data in the facility’s patient accounting system.)
- Chapter 10, Coding for Medical Necessity, contains tables that allow learners to organize answers to exercises. A chapter review contains evaluation and management coding practice exercises.
- Chapter 11, Essential CMS-1500 Claim Instructions, contains updated content, and information about automobile, disability, and liability insurance.
- Claims completion instructions in Chapters 12–17 are revised according to changes implemented by third-party and government payers. Claims completion instructions are located in an easy-to-read table format.
SUPPLEMENTS
Instructor’s Manual, contains the following sections:
- Section I - Preparing Your Course
- Section II - Answer Keys to Textbook Chapter Exercises and Reviews
- Section III - Chapter Exams and Answer Keys to Chapter Exams
- Section IV - Answer Keys to Textbook Appendix Case Studies
- Section V - Instructor’s Materials
- Section VI - Answer Keys to Workbook Chapter Assignments
- Section VII - Answer Key to Mock CMRS Exam
- Section VIII - Answer Key to Mock CPC-P Exam
Contents
- 1. Health Insurance Specialist Career.
- 2. Introduction to Health Insurance.
- 3. Managed Health Care.
- 4. Processing of an Insurance Claim.
- 5. Legal and Regulatory Issues.
- 6. ICD-9-CM Coding.
- 7. CPT Coding.
- 8. HCPCS Level II Coding.
- 9. CMS Reimbursement Methodologies.
- 10. Coding for Medical Necessity.
- 11. Essential CMS-1500 Claim Instructions.
- 12. Commercial Insurance.
- 13. Blue Cross Blue.
- 14. Medicare.
- 15. Medicaid.
- 16. TRICARE.
- 17. Workers' Compensation.
- APPENDICES.
- Bibliography.
- Glossary.
- Index.
About the Authors
- Michelle A. Green is a SUNY Distinguished Teaching Professor at Alfred State College in Alfred, New York. She is an active member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA). She is the recipient of many awards in recognition of her teaching excellence, including the State University of New York Chancellor's Award for Excellence in Teaching, Alfred State College Alumni Association's Teacher of the Year, AHIMA's Educator of the Year, and Alfred State College's first Innovator Award. Ms. Green holds an MPS, is a Registered Health Information Administrator (RHIA), a Fellow of the American Health Information Management Association (FAHIMA) and a Certified Professional Coder (CPC).
- Jo Ann C. Rowell ia a Founder and Former Chairperson, Medical Assisting Department Anne Arundel Community College, Arnold, MD.
Product Details
- Paperback: 687 pages
- Publisher: Delmar Cengage Learning; 10 Revised & enlarged edition (2011)
- Language: English
- ISBN-10: 1111035180
- ISBN-13: 978-1111035181
- Product Dimensions: 10.8 x 8.5 x 1.2 inches
List Price: $105.95