Preface Acknowledgments Part 1WORKING WITH MEDICAL INSURANCE AND BILLING Chapter 1 Introduction to the Medical Billing Cycle 1.1 Working in the Medical Insurance Field 1.2 Medical Insurance Basics 1.3 Health Care Plans 1.4 Health Maintenance Organizations 1.5 Preferred Provider Organizations 1.6 Consumer-Drive Health Plans 1.7 Medical Insurance Payers 1.

8 The Medical Billing Cycle 1.9 Achieving Success 1.10 Moving Ahead Chapter Review Chapter 2 Electronic Health Records, HIPAA, and HITECH: Sharing and Protecting Patients'' Health Information 2.1 Medical Record Documentation: Electronic Health Records 2.2 Health Care Regulation: HIPAA and HITECH 2.3 Covered Entities and Business Associates 2.4 HIPAA Privacy Rule 2.5 HIPAA Security Rule 2.

6 HITECH Breach Notification Rule 2.7 HIPAA Electronic Health Care Transactions and Code Sets 2.8 Fraud and Abuse Regulations 2.9 Enforcement and Penalties 2.10 Compliance Plans Chapter Review Chapter 3 Patient Encounters and Billing Information 3.1 New Versus Established Patients 3.2 Information for New Patients 3.3 Information for Established Patients 3.

4 Verifying Patient Eligibility for Insurance Benefits 3.5 Determining Preauthorization and Referral Requirements 3.6 Determining the Primary Insurance 3.7 Working with Encounter Forms 3.8 Understanding Time-of-Service (TOS) Payments 3.9 Calculating TOS Payments Chapter Review Part 2CLAIM CODING Chapter 4 Diagnostic Coding: Introduction to ICD-10-CM 4.1 ICD-10-CM 4.2 Organization of ICD-10-CM 4.

3 The Alphabetic Index 4.4 The Tabular List 4.5 ICD-10-CM Official Guidelines for Coding and Reporting 4.6 Overview of ICD-10-CM Chapters 4.7 Coding Steps 4.8 ICD-10-CM and ICD-9-CM Chapter Review Chapter 5 Procedural Coding: CPT and HCPCS 5.1 Current Procedural Terminology, Fourth Edition (CPT) 5.2 Organization 5.

3 Format and Symbols 5.4 CPT Modifiers 5.5 Coding Steps 5.6 Evaluation and Management Codes 5.7 Anesthesia Codes 5.8 Surgery Codes 5.9 Radiology Codes 5.10 Pathology and Laboratory Codes 5.

11 Medicine Codes 5.12 Category II and III Codes 5.13 HCPCS Chapter Review Chapter 6 Visit Charges and Compliant Billing 6.1 Compliant Billing 6.2 Knowledge of Billing Rules 6.3 Compliance Errors 6.4 Strategies for Compliance 6.5 Audits 6.

6 Physician Fees 6.7 Payer Fee Schedules 6.8 Calculating RBRVS Payments 6.9 Fee-Based Payment Methods 6.10 Capitation Chapter Review Part 3CLAIMS Chapter 7 Health Care Claim Preparation and Transmission 7.1 Introduction to Health Care Claims 7.2 Completing the CMS-1500 Claim: Patient Information Section 7.3 Types of Providers 7.

4 Completing the CMS-1500 Claim: Physician/Supplier Section 7.5 The HIPAA 837P Claim 7.6 Completing the HIPAA 837P Claim 7.7 Checking Claims Before Transmission 7.8 Clearinghouses and Claim Transmission Chapter Review Chapter 8 Private Payers/BlueCross BlueShield 8.1 Private Insurance 8.2 Features of Group Health Plans 8.3 Types of Private Payers 8.

4 Consumer-Driven Health Plans 8.5 Major Private Payers and the BlueCross BlueShield Association 8.6 Participation Contracts 8.7 Interpreting Compensation and Billing Guidelines 8.8 Private Payer Billing Management: Plan Summary Grids 8.9 Preparing Correct Claims 8.10 Capitation Management Chapter Review Chapter 9 Medicare 9.1 Eligibility for Medicare 9.

2 The Medicare Program 9.3 Medicare Coverage and Benefits 9.4 Medicare Participating Providers 9.5 Nonparticipating Providers 9.6 Original Medicare Plan 9.7 Medicare Advantage Plans 9.8 Additional Coverage Options 9.9 Medicare Billing and Compliance 9.

10 Preparing Primary Medicare Claims Chapter Review Chapter 10 Medicaid 10.1 The Medicaid Program 10.2 Eligibility 10.3 State Programs 10.4 Medicaid Enrollment Verification 10.5 Covered and Excluded Services 10.6 Plans and Payments 10.7 Third-Party Liability 10.

8 Claim Filing and Completion Guidelines Chapter Review Chapter 11 TRICARE and CHAMPVA 11.1 The TRICARE Program 11.2 Provider Participation and Nonparticipation 11.3 TRICARE Plans 11.4 TRICARE and Other Insurance Plans 11.5 CHAMPVA 11.6 Filing Claims Chapter Review Chapter 12 Workers'' Compensation and Disability/Automotive Insurance 12.1 Federal Workers'' Compensation Plans 12.

2 State Workers'' Compensation Plans 12.3 Workers'' Compensation Terminology 12.4 Claim Process 12.5 Disability Compensation and Automotive Insurance Programs Chapter Review Part 4CLAIM FOLLOW-UP AND PAYMENT PROCESSING Chapter 13 Payments (RAs), Appeals, and Secondary Claims 13.1 Claim Adjudication 13.2 Monitoring Claim Status 13.3 The Remittance Advice (RA) 13.4 Reviewing RAs 13.

5 Procedures for Posting 13.6 Appeals 13.7 Postpayment Audits, Refunds, and Grievances 13.8 Billing Secondary Payers 13.9 The Medicare Secondary Payer (MSP) Program, Claims, and Payments Chapter Review Chapter 14 Patient Billing and Collections 14.1 Patient Financial Responsibility 14.2 Working with Patients'' Statements 14.3 The Billing Cycle 14.

4 Organizing for Effective Collections 14.5 Collection Regulations and Procedures 14.6 Credit Arrangements and Payment Plans 14.7 Collection Agencies and Credit Reporting 14.8 Writing Off Uncollectible Accounts 14.9 Record Retention Chapter Review Chapter 15 Primary Case Studies 15.1 Method of Claim Completion 15.2 About the Practice 15.

3 Claim Case Studies Chapter Review Chapter 16 RA/Secondary Case Studies 16.1 Method of Claim Completion of Secondary Claims 16.2 Handling Denied Claims 16.3 Processing Medicare RAs and Preparing Secondary Claims 16.4 Processing Commercial Payer RAs and Preparing Secondary Claims 16.5 Calculating Patients'' BalancesChapter Review Part 5HOSPITAL SERVICES Chapter 17 Hospital Billing and Reimbursement 17.1 Health Care Facilities: Inpatient Versus Outpatient 17.2 Hospital Billing Cycle 17.

3 Hospital Diagnosis Coding 17.4 Hospital Procedure Coding 17.5 Payer and Payment Methods 17.6 Claims and Follow-up Chapter Review Chapter 18 Diagnostic Coding: Introduction to ICD-9-CM and ICD-10-CM AVAILABLE AT WWW.MCGRAWHILLCREATE.COM 18.1 ICD-9-CM 18.2 Organization of ICD-9-CM 18.

3 The Alphabetic Index 18.4 The Tabular List 18.5 Tabular List of Chapters 18.6 V Codes and E Codes 18.7 Coding Steps 18.8 Official Coding Guidelines 18.9 Introducing ICD-10-CM Chapter Review Appendix AGuide to Medisoft Part 1:Getting Started with Medisoft Part 2:Overview and Practice Appendix BGuide to the Interactive Simulated CMS-1500 Form Appendix CPlace of Service Codes Appendix DProfessional Websites Appendix EForms Abbreviations Glossary Index.