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E-raamat: Understanding Hospital Billing and Coding

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  • Ilmumisaeg: 26-Feb-2013
  • Kirjastus: W B Saunders Co Ltd
  • Keel: eng
  • ISBN-13: 9780323292269
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  • Formaat: PDF+DRM
  • Ilmumisaeg: 26-Feb-2013
  • Kirjastus: W B Saunders Co Ltd
  • Keel: eng
  • ISBN-13: 9780323292269
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A basic guide to hospital billing and reimbursement, Understanding Hospital Billing and Coding, 3rd Edition helps you understand, complete, and submit the UB-04 claim form that is used for all Medicare and privately insured patients. It describes how hospitals are reimbursed for patient care and services, showing how the UB-04 claim form reflects the flow of patient data from the time of admission to the time of discharge. Written by coding expert Debra P. Ferenc, this book also ensures that you understand the essentials of ICD-10-CM and develop skills in both inpatient coding and outpatient/ambulatory surgery coding.UB-04 Claim Simulation on the companion Evolve website lets you practice entering information from source documents into the claim form.Over 300 illustrations and graphics bring important concepts to life.Detailed chapter objectives highlight what you are expected to learn.Key terms, acronyms, and abbreviations with definitions are included in each chapter.Concept Review boxes reinforce key concepts.Test Your Knowledge exercises reinforce lessons as you progress through the material.Chapter summaries review key concepts.Practice hospital cases let you apply concepts to real-life scenarios.UPDATED content reflects the most current industry changes in ICD-10, MR-DRGs, PPS Systems, and the Electronic Health Record. NEW Hospital Introduction chapter includes a department-by-department overview showing how todays hospitals really workNEW Health Care Payers and Reimbursement section follows the workflow of the hospital claim by including successive chapters on payers, prospect payment systems, and accounts receivable management.
Section One Hospital Overview
1(100)
Chapter 1 Hospital Introduction
2(35)
Hospital Introduction
3(1)
Evolution of Hospitals
4(4)
Ancient Medicine and Healing Centers
4(1)
Classic Greece and Rome
5(1)
Middle Ages
6(2)
History of Hospitals in the United States
8(4)
Public Health Status
8(1)
Medical Practice
8(1)
Scientific Advances
9(1)
Medical Standards and Accreditation
9(2)
Economic Influences on Hospital Development
11(1)
Modern-Day Hospital Development
12(3)
Managed Care
12(1)
Reimbursement Systems
13(1)
Complex Hospital Systems
13(2)
Hospital Organizational Structure and Functions
15(2)
Hospital Functions Categorized
16(1)
Departmental Functions
17(9)
Administrative Functions
17(1)
Financial Functions
18(1)
Operational Functions
19(3)
Clinical Functions
22(4)
Hospital Classifications
26(2)
Hospital Organizations
26(1)
Hospital Types
27(1)
Hospital Services
28(1)
Diagnostic Services
28(1)
Therapeutic Services
28(1)
Palliative Services
28(1)
Preventive Services
28(1)
Hospital Service Levels
28(9)
Outpatient
28(2)
Inpatient
30(1)
Non-patient
30(7)
Chapter 2 Hospital Regulatory Environment
37(29)
Hospital Regulation
38(1)
Federal Legislation
39(5)
Access to and Quality of Health Care
40(3)
Health, Education, and Welfare
43(1)
Control the Rising Cost of Health Care
43(1)
Federal Regulatory Agencies
44(5)
Department of Labor
45(1)
Department of Veterans Affairs (VA)
45(1)
Department of Defense (DOD)
45(1)
TRICARE Management Activity (TMA)
45(1)
Department of Health and Human Services (DHHS)
45(1)
Center for Medicare and Medicaid Services (CMS)
46(1)
Office of Inspector General (OIG)
47(2)
State Regulations
49(1)
State Regulatory Agencies
49(1)
Department of Health (DOH)
49(1)
Agency for Health Care Administration (AHCA)
49(1)
State Hospital Licensing Requirements
50(5)
Minimum Hospital Licensing Requirements
50(1)
Additional Hospital Licensing Requirements
50(1)
Licensed Physician
51(1)
Nursing Services
51(1)
Admissions
52(1)
Patient Medical Record
53(1)
Health Information Management (HIM)
53(1)
Discharge Process
53(1)
Billing Process
54(1)
Purpose of Accreditation
55(2)
Accrediting Organizations
56(1)
Accreditation Process
57(1)
Non-Clinical Credentials
58(8)
American Academy of Professional Coders (AAPC)
58(1)
American Health Information Management Association (AHIMA)
59(1)
American Association of Healthcare Administrative Management (AAHAM)
60(6)
Chapter 3 Health Insurance Portability And Accountability Act (HIPAA)
66(35)
HIPAA Overview
67(1)
HIPAA Legislation
68(6)
HIPAA Title I Health Insurance Reform (Health Care Access, Portability, and Renewability)
68(1)
HIPAA Title II Preventing Health Care Fraud and Abuse and Administrative Simplification
68(6)
HIPAA Regulations
74(5)
Enforcement and Penalties
74(2)
State Laws and HIPAA
76(1)
Covered Entities
76(3)
HIPAA Title II Administrative Simplification (HIPAA-AS)
79(6)
Standard Transactions and Code Sets (TCS)
80(3)
Enforcement and Penalties
83(2)
HIPAA Title II Privacy Rule
85(6)
Protected Health Information (PHI)
85(1)
De-Identified Information
86(1)
Patient Privacy Rights
86(1)
HIPAA Privacy Practices
86(1)
Use and Disclosure of Protected Health Information (PHI)
86(4)
Enforcement and Penalties
90(1)
HIPAA Title II Security Rule
91(2)
Administrative Safeguards
91(1)
Technical Safeguards
92(1)
Physical Safeguards
92(1)
Enforcement and Penalties
93(1)
HIPAA Compliance
93(8)
OIG Compliance Program Guidance
93(1)
OIG Supplemental Compliance Program Guidance
94(1)
Fraud and Abuse Risk Areas
94(1)
Hospital Compliance Program Effectiveness and Self-Reporting
94(7)
Section Two Hospital Billing Process
101(74)
Chapter 4 Patient Accounts And Data Flow
102(36)
Patient Accounts and Data Flow
103(6)
Outpatient
104(1)
Ambulatory Surgery
105(3)
Inpatient
108(1)
Patient Care Process
109(2)
Patient Admission
111(2)
Preadmission Testing
111(1)
Utilization Review (UR)
112(1)
Admission Evaluation Protocols (AEP)
112(1)
Quality Improvement Organization (QIO)
113(1)
Admission Process
113(7)
Patient Interview
113(3)
Patient Registration
116(1)
Utilization Review (UR)
116(1)
Insurance Verification
116(2)
Patient's Medical Record (Chart)
118(1)
Room/Bed Assignment
119(1)
Admission Summary (Face Sheet)
119(1)
Census Update
119(1)
Medical Record Documentation
120(5)
Purpose of Documentation
121(1)
Content of the Patient's Medical Record
122(3)
Patient Care Services
125(3)
Common Categories of Hospital Services and Items
125(3)
Charge Capture
128(2)
Charge Capture Procedures
128(1)
Hospital Charges
129(1)
Patient Discharge
130(1)
Health Information Management (HIM) Procedures
130(1)
Hospital Billing Process
131(1)
Accounts Receivable (A/R) Management
132(6)
Chapter 5 Hospital Billing Process
138(37)
Purpose of the Billing Process
140(1)
Payer Guidelines
140(10)
Participating Provider Agreement (PAR)
141(2)
Charge Submission Requirements
143(2)
Reimbursement Methods
145(3)
Reimbursement Method Variations
148(2)
Charge Description Master (CDM)
150(5)
Hospital Services
151(1)
Hospital Service Categories
151(2)
Chargemaster Content
153(2)
Chargemaster Maintenance
155(1)
Coding Systems
155(6)
Procedure Coding Systems
156(1)
Diagnosis Coding Systems
156(1)
Coding System Variations
156(5)
Claim Forms
161(2)
CMS-1500
161(1)
CMS-1450 (UB-04)
161(1)
Detailed Itemized Statement
161(2)
Hospital Revenue Cycle
163(12)
Patient Admission and Registration
163(1)
Patient Care Services
164(1)
Charge Capture
164(1)
Chart Review and Coding
164(1)
Charge Submission
164(2)
Clean Claim
166(1)
Reimbursement
166(2)
Accounts Receivable (AR) Management
168(7)
Section Three Coding
175(176)
Chapter 6 ICD-9-CM Diagnosis And Procedure Coding
176(41)
History of Diagnosis Coding
177(3)
International List of the Causes of Death
178(1)
International Classification of Diseases (ICD)
178(1)
International Classification of Diseases, 9th Revision Clinical Modification (ICD-9-CM)
179(1)
International Classification of Diseases, 10th Revision (ICD-10)
179(1)
Purpose of Diagnosis Coding
180(2)
Diagnosis Code Data Usage
181(1)
Organizations Using Diagnosis Code Data
181(1)
Diagnosis Coding Relationships
182(5)
Documentation
182(1)
Medical Necessity
183(1)
Claim Forms
183(2)
Reimbursement
185(2)
ICD-9-CM Content
187(9)
ICD-9-CM Volume I Content
187(3)
ICD-9-CM Volume II Content
190(4)
ICD-9-CM Volume III Content
194(2)
ICD-9-CM Official Conventions
196(5)
Abbreviations and Symbols
196(2)
Instructional Notes
198(1)
Other Conventions
199(2)
Steps to Coding Using ICD-9-CM
201(4)
Step 1 Read the Record
201(1)
Step 2 Refer to the Alphabetic Index
201(2)
Step 3 Refer to the Tabular List
203(1)
Step 4 Sequence Codes
203(2)
ICD-9-CM Official Diagnosis Coding Guidelines
205(4)
General Diagnosis Coding Guidelines
205(1)
Diagnosis Coding Guidelines for Inpatient Services
206(1)
Selection of the Principal Diagnosis
206(1)
Reporting of Additional Diagnosis
207(1)
Present on Admission (POA) Reporting Guidelines
207(1)
Diagnosis Coding Guidelines for Outpatient Services
208(1)
ICD-9-CM Volume III Procedure Coding Guidelines
209(8)
General Procedure Coding Guidelines
209(1)
Guidelines for Selection of Principal and Other Procedures
209(8)
Chapter 7 ICD-10-CM Diagnosis Coding
217(42)
Evolution of Diagnosis Coding
218(2)
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
219(1)
International Classification of Diseases, 10th Revision (ICD-10)
219(1)
Impact of ICD-10
220(9)
Documentation
220(2)
Medical Necessity
222(1)
Claim Forms
223(4)
Reimbursement
227(2)
ICD-10-CM Data Usage
229(3)
Research
229(1)
Education
229(1)
Administration
230(1)
Organizations Using ICD-10-CM Data
230(2)
Transition to ICD-10-CM
232(6)
Differences in ICD-10-CM versus ICD-9-CM
232(2)
ICD-10 and Certification
234(1)
ICD-10-CM Mapping and Crosswalks
235(1)
ICD-10-CM Coordination and Maintenance Committee
235(3)
ICD-10-CM Content
238(7)
Volume I Tabular List of Diseases
238(1)
7th Character Extension
238(1)
External Causes of Morbidity (VØØ-Y99)
239(2)
Factors Influencing Health Status and Contact with Health Services (ZØØ-Z99)
241(1)
Volume II Official Guidelines
242(1)
Volume III Alphabetic Index to Diseases
243(1)
Volume III Index - Tables
243(2)
Alphabetic Index to External Causes of Injury
245(1)
ICD-10-CM Official Conventions
245(4)
ICD-10-CM Official Abbreviations and Symbols
246(2)
ICD-10-CM Official Instructional Notes
248(1)
ICD-10-CM Other Official Conventions
249(1)
Steps to Coding Diagnoses Using ICD-10-CM
249(10)
Step 1 Read the Record
249(1)
Step 2 Refer to ICD-10-CM Volume III, Alphabetic Index
249(1)
Step 3 Refer to ICD-10-CM Volume I, Tabular List
250(1)
Step 4 Sequence Codes
250(9)
Chapter 8 Procedure Coding (HCPCS And ICD-10-PCS)
259(47)
History of Procedure Coding
261(5)
Health Care Common Procedure Coding System (HCPCS)
261(1)
International Classification of Diseases (ICD) Procedure Codes
262(1)
Development of ICD-10
262(2)
Purpose of Procedure Coding
264(1)
Procedure Coding Defined
264(1)
Procedure Code Data Usage
265(1)
Procedure Coding Relationships
266(5)
Documentation
266(1)
Medical Necessity
267(1)
Claim Forms
268(2)
Reimbursement
270(1)
Procedure Coding System Variations
271(4)
Outpatient Services
271(1)
Non-Patient Services
272(1)
Inpatient Services
273(2)
HCPCS Level I-CPT
275(5)
HCPCS Level I CPT Content
276(2)
HCPCS Level I CPT Conventions and Format
278(2)
HCPCS Level II-Medicare National Codes
280(5)
HCPCS Level II Content
280(2)
HCPCS Level II Conventions and Format
282(3)
International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)
285(6)
ICD-10-PCS Code Format
286(1)
Character Meanings and Definitions
287(1)
ICD-10-PCS Content
288(1)
ICD-10-PCS Conventions
289(2)
ICD-10-PCS Guidelines
291(2)
Transition to ICD-10
292(1)
ICD-10 and Certification
292(1)
ICD-10 Mapping and Crosswalks
292(1)
ICD-10 Coordination and Maintenance Committee
292(1)
Steps to Coding Using HCPCS and ICD-10-PCS
293(13)
Step 1 Read the Medical Record
293(1)
Step 2 Refer to the Alphabetic Index
293(2)
Step 3 Refer to the Code Sections for Code Assignment
295(1)
Step 4 Identify Modifier Circumstances
296(1)
Step 5 Sequence Codes
297(9)
Chapter 9 Coding Guidelines And Applications (HCPCS, ICD-10-PCS, And ICD-10-CM)
306(45)
Relationship Between Billing and Coding
307(6)
Documentation
308(1)
Claim Form Submission
308(1)
Payer Processing
309(4)
Coding System Variations
313(4)
Outpatient and Non-patient Services
313(1)
Inpatient Services
313(4)
ICD-10-CM Official Diagnosis Coding Guidelines
317(10)
ICD-10-CM General Diagnosis Coding Guidelines
317(2)
ICD-10-CM Outpatient Diagnosis Coding Guidelines
319(1)
ICD-10-CM Inpatient Diagnosis Coding Guidelines
320(1)
Selection of the Principal Diagnosis
320(2)
Reporting of Additional Diagnosis
322(1)
ICD-10-CM Present on Admission (POA) Reporting
322(2)
ICD-10-CM Coding Guidelines (Outpatient versus Inpatient)
324(3)
HCPCS Coding Guidelines
327(7)
HCPCS General Procedure Coding Guidelines
327(1)
HCPCS Level I CPT Coding Guidelines
328(2)
HCPCS Level II Medicare National Coding Guidelines
330(4)
ICD-10-PCS General Coding Guidelines
334(1)
Selection of Principal and Other Procedures
334(1)
ICD-10-PCS Official Coding Guidelines
334(6)
Body System General Guidelines B2.1a-B2.1b
335(1)
Root Operation General Guidelines B3.1a-B3.16
335(2)
Body Part Guidelines B4.1a-B4.7.11
337(1)
Approach Guidelines B5.2-B5.4
338(1)
Device Guidelines B6
339(1)
Steps to Coding Diagnoses and Procedures
340(11)
Coding Resources
341(10)
Section Four Claim Forms
351(34)
Chapter 10 Claim Forms
352(33)
Purpose of Claim Forms
353(1)
Claim Form Submission
353(4)
Manual Claim Submission
354(1)
Electronic Claim Submission
355(2)
Claim Form Variations
357(2)
CMS-1500 Claim Form Overview
359(1)
Claim Form Data
359(1)
CMS-1450 (UB-04) Claim Form Overview
359(2)
Claim Form Data
359(1)
Section I Facility, Patient, Admission, Discharge, Occurrence, and Value Information (FL 1 to 41)
359(2)
Section II Charge Information (FL 42 to 49)
361(1)
Section III Payer, Insured, Employer, and Authorization Information (FL 50 to 65)
361(1)
Section IV Procedure, Diagnosis, and Provider Information (FL 66 to 81)
361(1)
CMS-1450 (UB-04) Instructions
361(24)
Section Five Health Care Payers and Reimbursement
385(120)
Chapter 11 Health Care Payers
386(45)
Types of Health Insurance Plans
388(7)
Traditional Fee-for-Service Plans
388(1)
Managed Care Plans
389(6)
Third-Party Payers
395(1)
Private Payers
395(2)
Group Health Insurance
396(1)
Individual Health Insurance
396(1)
Other Health Insurance
396(1)
Personal Injury Insurance
396(1)
Automobile Insurance
396(1)
Workers' Compensation Insurance
397(1)
Government Payers
397(7)
Medicare
397(1)
Medicare Administrative Contractor (MAC)
398(1)
Eligibility
399(1)
Coverage
399(1)
Medicare Part A
399(1)
Medicare Part B
400(1)
Medicare Part C
401(1)
Medicare Part D
402(1)
Plan Options
402(1)
Coordination of Benefits (COB)
403(1)
Medicare Secondary Payer (MSP)
403(1)
Medicaid
404(2)
Fiscal Agent (FA)
404(1)
Eligibility
404(1)
Coverage
405(1)
Plan Options
405(1)
Coordination of Benefits (COB)
405(1)
Children's Health Insurance Program (CHIP)
406(1)
Eligibility
406(1)
Coverage
406(1)
TRICARE and CHAMPVA
407(6)
Regional Contractors
407(1)
Eligibility
408(1)
Coverage
408(1)
Plan Options
408(1)
TRICARE Prime
408(1)
TRICARE Extra
409(1)
TRICARE Standard
410(1)
Other TRICARE Programs
411(1)
CHAMPVA
411(1)
Coordination of Benefits (COB)
411(2)
Insurance Plan Terms and Specifications
413(18)
Participating Provider Agreement (PAR)
413(1)
Medical Necessity
413(1)
Coverage
413(3)
Coordination of Benefits (COB)
416(3)
Birthday Rule
419(1)
Patient Responsibility
419(1)
Copayment (Copay)
420(1)
Coinsurance
420(1)
Deductible
420(1)
Reimbursement
421(1)
Traditional Methods
422(1)
Fixed-Payment Methods
422(1)
Prospective Payment Systems (PPS) Methods
422(1)
Billing Requirements
422(1)
Documentation
422(1)
Coding
423(1)
Claim Forms
423(1)
Timely Filing
423(8)
Chapter 12 Prospective Payment Systems (PPS)
431(38)
Prospective Payment Systems (PPS) Defined
432(1)
Prospective Payment System (PPS) Evolution
432(4)
Inpatient Prospective Payment System (IPPS)
433(1)
Outpatient Prospective Payment System (OPPS)
433(1)
Other Prospective Payment Systems
434(2)
Inpatient Prospective Payment System (IPPS)
436(12)
DRG Development
436(1)
MS-DRG Structure
437(4)
Coding for MS-DRG Assignment
441(3)
MS-DRG Assignment
444(1)
MS-DRG Grouper Program
444(1)
MS-DRG Payment Calculations
445(1)
MS-DRG Outlier/Inlier
446(2)
Outpatient Prospective Payment System (OPPS)
448(5)
APC Development
449(1)
APC Structure
450(1)
APC Categories
451(2)
APC Packaged Services
453(1)
APC Payment Status Indicators (SI)
453(1)
APC Inpatient Only Procedures
453(1)
APC Multiple Procedure Reduction
454(1)
Coding for APC Assignment
455(5)
Diagnosis Coding
455(1)
Procedure Coding
456(1)
Healthcare Common Procedure Coding System (HCPCS)
456(1)
HCPCS Level I CPT Procedure Coding
456(2)
HCPCS Level I CPT Modifiers
458(1)
HCPCS Level II Medicare National Codes
459(1)
HCPCS Level II Modifiers
459(1)
APC Assignment
460(1)
APC Grouper Program
460(1)
APC Payment Calculations
461(1)
APC Outlier/Inlier
461(1)
APC Transitional Pass-Through Payments
462(7)
Chapter 13 Accounts Receivable (A/R) Management
469(36)
Life Cycle of a Hospital Claim
470(1)
Hospital Billing Process
471(4)
Payer Processing
472(1)
Payer's Data File
472(1)
Computer Edits
473(1)
Payment Determination
474(1)
Remittance Advice (RA)
475(2)
Remittance Advice Data Elements
475(1)
Analyzing a Remittance Advice
475(2)
Patient Transactions
477(2)
Patient Payments
477(1)
Third-Party Payer Payments
477(1)
Adjustments
478(1)
Balance Billing
479(3)
Secondary Billing
482(1)
Accounts Receivable (A/R) Management
483(7)
Accounts Receivable (A/R) Reports
484(1)
Accounts Receivable (A/R) Aging Report
484(2)
Denials Management Report
486(1)
Financial Class Reports
486(1)
Unbilled Accounts Report
486(2)
Accounts Receivable (A/R) Procedures
488(1)
Lost Claim
488(1)
Rejected Claim
489(1)
Denied Claim
489(1)
Pended Claim
489(1)
Credit and Collection Laws
490(2)
Statute of Limitations
490(1)
Fair Credit Billing Act
490(1)
Fair Debt Collection Practices Act
490(2)
Collection Activities
492(6)
Prioritizing Collection Activities
493(1)
Patient Account Follow-Up Procedures
493(1)
Patient Statements
493(1)
Patient Phone Contact
493(1)
Collection Letters
494(1)
Third-Party Payer Account Follow-Up Procedures
494(1)
Prompt Pay Statutes
495(1)
Insurance Telephone Claim Inquiry
496(1)
Insurance Computer Claim Inquiry
496(1)
Insurance Claim Tracer
496(1)
Uncollectible Patient Accounts
497(1)
Insurance Commissioner Inquiries
497(1)
Appeals Process
498(7)
Claim Determinations That Can Be Appealed
498(1)
Who Can Request an Appeal
498(1)
Time Requirement for Appeal Submission
498(1)
Levels of Appeal
498(1)
Appeal Submission Procedures
499(6)
Section Six Appendixes
505(82)
A Cases
506(59)
B Claim Form Data
565(17)
C List of Web Resources
582(5)
Index 587