Introduction 1 About This Book 1 Foolish Assumptions 2 Icons Used in This Book 2 Beyond the Book 3 Where to Go from Here 3 Part 1: Getting to Know Medical Billing and Coding 5 Chapter 1: Dipping Your Toes into Medical Billing and Coding 7 Coding versus Billing: They Really Are Two Jobs 8 Following a Day in the Life of a Claim 9 Keeping Abreast of What Every Biller/Coder Needs to Know 10 Complying with federal and state regulations 10 Learning the lingo: Medical terminology 11 Demonstrating medical necessity 11 Deciding Which Job Is Right for You 11 Examining your workplace options 12 Thinking about your dream job 12 Prepping for Your Career: Training Programs and Certifications 13 Previewing your certification options 13 Going back to school 14 Planning for the Future 15 Chapter 2: Exploring the Billing and Coding Professions 17 Looking at the Medical Coding Job 18 Verifying documentation 18 Following up on unclear documentation 21 Assigning diagnosis and procedure codes 21 Transforming visits into revenue 22 Determining whether medical coding suits you 23 Breaking Down the Medical Biller''s Job 23 Knowing the payers and keeping up on their idiosyncrasies 24 Billing each payer correctly 25 Checking the claim over prior to submission 27 Assessing whether medical billing is the right choice for you 27 In Tandem: Working Together or Doing Both Jobs Yourself? 28 Wearing both hats 28 Deciding which job is for you 29 Chapter 3: Weighing Your Employment Options 31 Choosing Your Environment: Doctor''s Office, Hospital, and Others 32 The doctor is in: Working in a physician''s office 33 Hooking up with a hospital 33 Focusing on a billing or practice management company 34 Processing claims for an insurance company 35 Considering the best of the rest 36 Getting your foot in the door 36 Remote Access: Setting up Off-Site 37 Working in your PJs 37 The no-commute commute: Arranging a suitable workspace 38 Looking at the downside of working remotely 38 Reviewing Other Work Options: Freelancing, Temping, and More 39 Heeding a Word of Advice for New Coders 40 Part 2: Boning Up on the Need-to-Knows of Your Profession 43 Chapter 4: Compliance: Understanding the Rules 45 You Rule! Meeting the Rule Makers 46 The Centers for Medicare & Medicaid Services (CMS) 46 The Office of Inspector General (OIG) 47 The individual payer (insurance company) 47 Complying with HIPAA 48 Doing your part: Do''s and don''ts of compliance 49 Uh-oh! Facing the consequences of non-compliance 53 Unbundling the Compliance Bundle 53 Looking at incidental procedures 54 Identifying when separately reporting is okay 54 Recognizing when unbundling''s not okay 55 Defining exclusivity 55 Getting the Most out of the Dreaded Audit 57 Distinguishing between internal and payer audits 58 Guarding against an RAC audit 58 Avoiding an audit: You can''t 59 Protecting yourself from an audit 59 Chapter 5: Not-So-Strange Bedfellows: Medical Terminology and Medical Necessity 61 Brushing Up on Basic Anatomy 62 Getting familiar with body systems 62 Getting a handle on illness and disease 64 Encountering injuries 64 Say What? Deciphering Medical Terminology 65 In the beginning: Knowing your prefixes 65 Sussing out the suffixes 67 Eureka! Putting them together 67 Understanding Medical Necessity 69 Scrubbing In: Proving Medical Necessity for Surgical Procedures 70 Checking out endoscopic procedures 70 Examining open surgical procedures 73 Understanding incidentals and when procedures can be separately reported 75 Using billing modifiers 75 Connecting with the World of Evaluation and Management Codes 76 Looking at what happens during the run-of-the-mill E&M visit 77 Visiting the office 78 Visiting the hospital 80 Dealing with consultation visits 82 Determining the level of billable service 83 Chapter 6: Getting to Know the Payers 85 Wading through Commercial Insurance Payers 86 Identifying the carriers 87 Tuning in to networks 89 Choosing third-party administrators 89 Medicare: Meeting the Chief Government Payer 90 Examining Medicare, part by part 91 Looking at Medicare supplement policies 93 Coding and processing Medicare claims 94 Working with Other Government Payers 95 Patient Protection and Affordable Care Act (ACA) 95 Medicaid 96 Tricare (Department of Defense) 98 CHAMPUS VA (Department of Veterans Affairs) 99 Office of Workers'' Compensation Programs (Department of Labor) 100 Part 3: Becoming a Professional: Getting Certified 103 Chapter 7: Your Basic Certification Options, Courtesy of the AAPC and AHIMA 105 Introducing the Two Main Credentialing Organizations: AAPC and AHIMA 106 Going with AAPC 106 Choosing AHIMA instead 106 Being a joiner: The benefits of membership 107 Joining one or both: The pros and cons of multiple membership 107 Looking at the Basic Certifications 108 AAPC and its basic certifications: CPC, COC, CPC-P, CIC 108 AHIMA and its basic certifications: CCA, CCS, CCS-P 110 Choosing the Certification That''s Right for You 111 Examining the educational requirements 112 Prioritizing your career needs 112 Seeing what employers in your area want 113 Examining the Exams: A Quick Review of the Main Tests 113 The CPC exam (AAPC) 114 The CCS exam (AHIMA) 116 The CCA exam (AHIMA) 117 Chapter 8: The Path to Certification: Finding a Study Program 119 The Big Picture: Thinking about Your Degree and Career Objectives 120 Prioritizing your career needs 120 Determining what kind of program better meets your needs 121 Deciding whether you want to pursue a degree 122 Considering the Time Commitment 122 Planning for your time-to-degree 122 Anticipating your day-to-day schedule 124 First Things First: Squaring Away Your Prerequisites 125 Preparing for your training program 125 Getting ready for the certification test 126 Picking a Program of Study 127 In your backyard: Community college 128 Vocation station: Technical school programs 130 Clicking the mouse: Online training 133 Caveat Emptor: Watching Out for Diploma Mills 136 Chapter 9: Signing Up and Preparing for the Certification Exam 139 Establishing a Study Routine and Strategy 139 Setting up your own space 140 Clearing your calendar for study 141 Developing a study strategy 141 Focusing on the Right Topics 142 Identifying body systems 143 Understanding medical terminology 148 Boning up on insurer and payer rules 150 Preparing Yourself for Test Day 151 Finding ways to stress less 151 Knowing how to use your resources 152 Signing Up for and Taking the Big Test 153 Taking a quick peek at the exam 154 Making the grade -- or not 156 Tackling test-taking tips 156 Chapter 10: Adding Street Cred: Specialty Certifications and Continuing Ed 159 Introducing Specialty Certification Options 160 Eyeing AAPC trademarked certifications 160 Showing off specialty AHIMA certifications 160 Perusing the best of the rest 165 Building on Your Cred with Continuing Education 166 Adding up the continuing ed units (CEUs) 166 Earning the units you need 167 Digging up complimentary CEU resources 167 Getting the most bang for your buck with CEUs 168 Part 4: Dealing and Succeeding with Nitty-Gritty On-the-Job Details 171 Chapter 11: Processing a Run-of-the-Mill Claim: An Overview 173 Dreaming of the Perfect Billing Scenario 173 Completing the initial paperwork 174 Getting the documentation about the patient encounter with the provider 175 Entering the codes into the billing software 175 Show me the money! Letting the payer take its turn 176 Delving into the Details: Contract Specifics 177 Understanding who''s contracting whom? 177 Looking at standard contracts 178 Cutting through reimbursement rates and carve-outs 179 Covering Your Bases: Referrals and Preauthorization 179 Checking for referrals 180 Dealing with prior authorization 180 Tracking Your Claim from Submission to Payment 182 Working with billing software 182 Passing from provider to clearinghouse 183 And going on to the payer 185 Scoring the payment or going into negotiation 186 Fighting for Proper Payment: Filing an Appeal with the Payer 188 Chapter 12: Homing In on How to Prepare an Error-Free Claim 191 Assigning CPT Codes 192 Getting the lowdown on CPT codes and fee schedules 192 Knowing the rules governing which codes you can use 193 Linking your CPT codes to ICD-10-CM codes 194 Making your code as specific as possible 194 Paying attention to your bundle of joy 197 Applying Modifiers Correctly 199 Using modifiers for com.