Strengthen your skills and develop a solid foundation for professional success with Green's UNDERSTANDING HEALTH INSURANCE: A GUIDE TO BILLING AND REIMBURSEMENT, 2023 Edition. This reader-friendly, comprehensive resource provides a practical, up-to-date guide to current medical code sets and coding guidelines, preparing you to assign ICD-10-CM, CPT® and HCPCS Level II 2023 codes; complete health insurance claims; and master key revenue management concepts. You'll focus on important topics such as managed care, legal and regulatory issues, coding systems and compliance, reimbursement methods, clinical documentation improvement, coding for medical necessity and common health insurance plans. The current edition introduces the MIPS Value Pathways; explains major changes for selecting codes in the CPT 2023 evaluation and management section; and clarifies key health insurance concepts such as risk adjustments, hierarchical condition category coding, patient portals, balance billing, coordination of benefits, third-party administrators, Medicare appeals process and whistleblowers. In addition, a helpful workbook provides hands-on assignments and case studies, while MindTap online resources offer interactive practice in completing CMS-1500 claims and assigning codes.
1. Health Insurance Specialist Career.
2. Introduction to Health Insurance and Managed Care.
3. Introduction to Revenue Management.
4. Revenue Management: Insurance Claims, Denied Claims and Appeals and Credit and Collections.
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.
14. Medicare.
15. Medicaid.
16. TRICARE.
17. Workers’ Compensation.
Appendices.
Bibliography.
Glossary.
Index.
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Michelle Green
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.
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The 2023 Edition features updated health insurance and medical billing concepts throughout the text, focusing on the MIPS Value Pathways and major changes for selecting codes in the CPT® 2023 evaluation and management section. The new edition also clarifies key health insurance concepts such as risk adjustments, the hierarchical condition category system, patient portals, balance billing, coordination of benefits, third-party administrators, Medicare appeals process and whistleblowers.
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The author has carefully updated all instructions for completing insurance claims within chapters 11-17. Revisions reflect the latest requirements to prepare students to seamlessly transition their skills from academic to professional environments.
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Updated for 2023, chapter 3 provides current information on revenue management, managing patients, encounter forms and chargemasters, processing an insurance claim, posting charges to patient accounts, monitoring and auditing for revenue management. Featuring similar updates for today's industry, chapter 4 covers the insurance claim cycle, maintaining insurance claim files, denied claims, the appeals process and credit and collections.
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Updates to ICD-10-CM content reflect the latest changes and developments students need to know, reorganizing key coding concepts to align them with official CMS coding guidelines.
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CPT® codes and concepts have been updated throughout this edition, including an emphasis on major changes for assigning codes to the evaluation and management section in CPT 2023.
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Chapters 6-17 include new and revised ICD-10-CM, CPT® and HCPCS Level II codes for 2023. All explanations, exercises and reviews within these chapters reflect the latest coding changes, the most up-to-date coding guidelines and their impact on the assigning of codes.
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Clear learning objectives at the beginning of each chapter allow students to self-assess comprehension of chapter content. In addition, boldfaced key terms appear throughout each chapter to help students master the technical vocabulary associated with billing, coding, reimbursement and claims processing. The text's proven learning design methodology clearly maps chapter content both to major topics to be covered and to well-defined learning objectives.
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Clear instructions for completing CMS-1500 insurance claims reflect current requirements, including any recent changes. Updates to instructions appear throughout the textbook and SimClaim software, as well as within the answer keys in the solutions and answer guide. Case studies in the SimClaim software present billing data and patient histories, which students can use to complete data entry of CMS-1500 claims and receive immediate feedback.
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The student companion website features the latest content on ICD-10-PCS coding and official guidelines, as well as a variety of application exercises to strengthen coding skills. Answer keys are available on the password-protected instructor's companion website.
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Review questions incorporate payment calculations to give students hands-on practice in calculating insurance or Medicare payments, co-payments and coinsurance, encouraging them to develop these important skills for career success.
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Multiple-choice review questions help accurately assess student comprehension of chapter content, while additional questions focus on gauging understanding of key concepts and applications.
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To gain valuable hands-on practice with key concepts, students can complete coding exercises throughout chapters 6-8 and 10, as well as claims completion exercises in chapters 11-17. Answers to all of these exercises are available in the solutions and answer guide to make assessment easier.
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