Develop the skills and background for a career in medical billing and insurance processing or revenue management with Green's UNDERSTANDING HEALTH INSURANCE: A GUIDE TO BILLING AND REIMBURSEMENT, 2021 Edition. This complete resource explains the latest medical code sets and coding guidelines as you learn how to assign ICD-10-CM, CPT, and HCPCS level II codes; complete health care claims and master revenue management concepts. You focus on today’s most important topics, including managed care, legal and regulatory issues, coding systems and compliance, reimbursement methods, clinical documentation improvement, coding for medical necessity and common health insurance plans. Updates address changes to ICD-10-CM and CPT 2021 codes and introduce electronic claims processing, clinical quality language and other developments. A helpful workbook provides assignments; case studies and CPC-P and CPB mock exams, while MindTap online resources offer practice in CMS-1500 claims and assigning codes.
1. Health Insurance Specialist Career.
2. Introduction to Health Insurance.
3. Managed Health Care.
4. Revenue Cycle Management.
5. Legal Aspects of Health Insurance and Reimbursement.
6. ICD-10-CM Coding.
7. CPT Coding.
8. HCPCS Level II Coding.
9. CMS Reimbursement Methodologies.
10. Coding Compliance, Clinical Documentation Improvement, and Coding for Medical Necessity.
11. CMS-1500 and UB-04 Claims.
12. Commercial Insurance.
13. BlueCross BlueShield.
17. Workers’ Compensation.
Michelle Green has been a SUNY Distinguished Teaching Professor in the health information technology department at Mohawk Valley Community College in Utica, New York, since 2017. Ms. Green held the position of SUNY Distinguished Teaching Professor in the physical and life sciences department at the State University of New York, College of Technology for more than 30 years. An active member of the American Academy of Professional Coders (AAPC) and American Health Information Management Association (AHIMA), Ms. Green has been recognized both for her excellence in teaching and for her significant contributions to the health information management profession. She has earned numerous awards, including the State University of New York Chancellor’s Award for Excellence in Teaching, Alfred State College’s Alumni Association Teacher of the Year, Who’s Who Among America’s Teachers and AHIMA’s FORE Triumph Educator Award. Ms. Green is a registered health information administrator (RHIA), a fellow of the American Health Information Management Association (FAHIMA) and a certified procedural coder (CPC). She earned an M.P.S. degree from Alfred University and a B.S. from Daemen College. Ms. Green has authored three popular textbooks related to coding, revenue management and health information management.
ANNUAL UPDATES ENSURE THE LATEST CONTENT AND DEVELOPMENTS IN HEALTH INSURANCE AND MEDICAL BILLING. This edition includes new content discussing the National Healthcare Association (NHA) and its Certified Billing & Coding Specialist (CBCS) certification in Chapter 1.
NEW COVERAGE INTRODUCES READERS TO CLINICAL QUALITY LANGUAGE (CQL). New content in Chapter 2 details this all-new clinical language that is becoming critical for CQL-based quality measures today.
CHAPTER 4 NOW FOCUSES ON ELECTRONIC CLAIMS PROCESSING. Students examine the benefits and limitations of electronic claims processing today as they learn how to use this increasingly popular paperless option that more and more practitioners are relying upon to facilitate the claim reimbursement process.
NEW COVERAGE OF THE TARGETED PROBE AND EDUCATE (TPE) PROCESS FOR MEDICAL REVIEW NOW APPEARS IN CHAPTER 5. Students learn about CMS's Targeted Probe and Educate (TPE) program, designed to help providers and suppliers reduce claim denials and appeals. Insightful discussion helps readers prepare to work with TPE in a professional role, should the need arise.
UPDATES TO ICD-10-CM CONTENT REFLECT THE LATEST DEVELOPMENTS. New content within Chapter 6 now details the new ICD-10-CM Chapter 22: Codes for Special Purposes (U00–U85) as well as the CDC's new ICD-10-CM search tool website (https://icd10cmtool.cdc.gov). Corresponding online resources for this edition present additional content and updates for ICD-10-PCS coding.
NEW COVERAGE HIGHLIGHTS THE LATEST CPT® 2021 CHANGES. Chapter 7 is now updated to major revisions to the evaluation and management CPT 2021 codes and descriptions. Students learn what must be removed, new requirements for report codes 99202-99215, the basis for code selection and the changing definition of the time element associated with codes.
UPDATES TO CONTENT IN CHS. 6-17 INTEGRATES NEW AND REVISED ICD-10-CM, CPT AND HCPCS LEVEL II CODES. All material in Chapters 6 through 17, including explanations, exercises and activities, now reflects the latest changes in today's coding systems.
CHAPTER 9 PROVIDES NEW CONTENT RELATED TO HOME HEALTH PROSPECTIVE PAYMENT. Students examine the latest information about the Home Health Prospective Payment's patient-driven groupings model. They also review data management content about the collection and use of standardized patient assessment data elements (SPADE) for post-acute care (PAC) quality measures.
EXPLANATIONS IN CHAPTER 10 NOW INCLUDE A NEW REFERENCE TO CLINICAL DOCUMENTATION INTEGRITY (CDI). Students learn how clinical documentation integrity (CDI) differs as an alternative to clinical documentation improvement (CDI). Students examine how clinical documentation integrity programs focus on clinical documentation excellence and are essential within most healthcare facilities.
UPDATED INSTRUCTIONS GUIDE STUDENTS THROUGH ACCURATELY COMPLETING INSURANCE CLAIMS. All insurance claims completion instructions within Chapters 11 through 17 are updated to reflect the latest requirements and to prepare students to seamlessly transition skills to a professional environment.
LEARNING DESIGN METHODOLOGY WITH CLEAR OBJECTIVES GUIDES READER UNDERSTANDING. This edition's learning design methodology clearly maps chapter content to both major topics and well-defined learning objectives to keep students focused and progressing.
UPDATED CONTENT ADDRESSES THE LATEST DEVELOPMENTS IN THE FIELD TODAY. Revised chapter content throughout this edition highlights the latest updates in revenue management, reimbursement methods, health insurance processing and medical coding.
ONLINE TOOLS ASSIST IN MASTERY OF ICD-10-PCS CODING AND GUIDELINES. Content about ICD-10-PCS coding and official guidelines are located at the student online companion website with a variety of application exercises to strengthen coding skills. Answer keys are conveniently located on the password-protected instructor's companion website.
UPDATED INSTRUCTIONS INCORPORATE THE LATEST CHANGES IN COMPLETING TODAY'S INSURANCE CLAIMS. Clear instructions for completing CMS-1500 insurance claims reflect the today's requirements and the latest changes. All updates to instructions continue throughout the printed book and SimClaim software as well as the answer keys in the instructor’s manual.
REVIEW QUESTIONS REQUIRE PAYMENT CALCULATIONS TO HELP STRENGTHEN SKILLS. Students gain important practice in calculating insurance or Medicare payments, co-payments and coinsurance as they complete this edition's review questions. The author has incorporated these requirements to ensure students have the practice necessary to master these important skills.
VARIETY OF NEW AND REVISED REVIEW QUESTIONS ENSURE STUDENT UNDERSTANDING. Revised multiple-choice review questions more accurately assess student comprehension, while additional, new questions check student understanding of the latest key concepts and applications.
ONLINE SIMCLAIM SOFTWARE WITHIN MINDTAP PROVIDES PROFESSIONAL HANDS-ON PRACTICE. Case studies in the SimClaim software present billing data and patient histories. Students complete data entry of CMS-1500 claims and receive immediate feedback. Clear instructions for using SimClaim software appear at the end of the printed book's preface for user convenience.
KEY TERMS, SECTION HEADINGS AND LEARNING OBJECTIVES ORGANIZE AND DIRECT LEARNING. Students can use the clear learning objectives at the beginning of each chapter as a self-test for checking comprehension and mastery of chapter content. In addition to well organized content, boldfaced key terms appear throughout each chapter to help students master the technical vocabulary associated with claims processing.
CODING AND CLAIMS COMPLETION EXERCISES ALLOW STUDENTS TO PRACTICE CONCEPTS AS THEY PROGRESS. Students complete coding exercises throughout Chapters 6, 7, 8 and 10 and complete claims completion exercises in Chapters 11 through 17. Answers to all of these exercises are available in the instructor’s manual for your convenience in checking student work.
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