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Section One Hospital Overview |
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1 | (100) |
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Chapter 1 Hospital Introduction |
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2 | (35) |
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3 | (1) |
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4 | (4) |
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Ancient Medicine and Healing Centers |
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4 | (1) |
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5 | (1) |
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6 | (2) |
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History of Hospitals in the United States |
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8 | (4) |
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8 | (1) |
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8 | (1) |
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9 | (1) |
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Medical Standards and Accreditation |
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9 | (2) |
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Economic Influences on Hospital Development |
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11 | (1) |
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Modern-Day Hospital Development |
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12 | (3) |
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12 | (1) |
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13 | (1) |
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13 | (2) |
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Hospital Organizational Structure and Functions |
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15 | (2) |
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Hospital Functions Categorized |
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16 | (1) |
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17 | (9) |
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17 | (1) |
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18 | (1) |
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19 | (3) |
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22 | (4) |
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26 | (2) |
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26 | (1) |
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27 | (1) |
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28 | (1) |
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28 | (1) |
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28 | (1) |
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28 | (1) |
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28 | (1) |
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28 | (9) |
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28 | (2) |
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30 | (1) |
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30 | (7) |
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Chapter 2 Hospital Regulatory Environment |
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37 | (29) |
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38 | (1) |
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39 | (5) |
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Access to and Quality of Health Care |
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40 | (3) |
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Health, Education, and Welfare |
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43 | (1) |
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Control the Rising Cost of Health Care |
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43 | (1) |
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Federal Regulatory Agencies |
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44 | (5) |
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45 | (1) |
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Department of Veterans Affairs (VA) |
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45 | (1) |
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Department of Defense (DOD) |
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45 | (1) |
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TRICARE Management Activity (TMA) |
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45 | (1) |
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Department of Health and Human Services (DHHS) |
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45 | (1) |
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Center for Medicare and Medicaid Services (CMS) |
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46 | (1) |
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Office of Inspector General (OIG) |
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47 | (2) |
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49 | (1) |
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State Regulatory Agencies |
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49 | (1) |
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Department of Health (DOH) |
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49 | (1) |
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Agency for Health Care Administration (AHCA) |
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49 | (1) |
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State Hospital Licensing Requirements |
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50 | (5) |
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Minimum Hospital Licensing Requirements |
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50 | (1) |
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Additional Hospital Licensing Requirements |
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50 | (1) |
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51 | (1) |
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51 | (1) |
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52 | (1) |
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53 | (1) |
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Health Information Management (HIM) |
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53 | (1) |
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53 | (1) |
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54 | (1) |
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55 | (2) |
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Accrediting Organizations |
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56 | (1) |
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57 | (1) |
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58 | (8) |
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American Academy of Professional Coders (AAPC) |
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58 | (1) |
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American Health Information Management Association (AHIMA) |
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59 | (1) |
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American Association of Healthcare Administrative Management (AAHAM) |
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60 | (6) |
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Chapter 3 Health Insurance Portability And Accountability Act (HIPAA) |
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66 | (35) |
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67 | (1) |
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68 | (6) |
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HIPAA Title I Health Insurance Reform (Health Care Access, Portability, and Renewability) |
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68 | (1) |
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HIPAA Title II Preventing Health Care Fraud and Abuse and Administrative Simplification |
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68 | (6) |
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74 | (5) |
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Enforcement and Penalties |
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74 | (2) |
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76 | (1) |
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76 | (3) |
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HIPAA Title II Administrative Simplification (HIPAA-AS) |
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79 | (6) |
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Standard Transactions and Code Sets (TCS) |
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80 | (3) |
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Enforcement and Penalties |
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83 | (2) |
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HIPAA Title II Privacy Rule |
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85 | (6) |
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Protected Health Information (PHI) |
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85 | (1) |
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De-Identified Information |
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86 | (1) |
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86 | (1) |
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86 | (1) |
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Use and Disclosure of Protected Health Information (PHI) |
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86 | (4) |
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Enforcement and Penalties |
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90 | (1) |
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HIPAA Title II Security Rule |
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91 | (2) |
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Administrative Safeguards |
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91 | (1) |
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92 | (1) |
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92 | (1) |
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Enforcement and Penalties |
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93 | (1) |
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93 | (8) |
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OIG Compliance Program Guidance |
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93 | (1) |
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OIG Supplemental Compliance Program Guidance |
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94 | (1) |
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Fraud and Abuse Risk Areas |
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94 | (1) |
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Hospital Compliance Program Effectiveness and Self-Reporting |
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94 | (7) |
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Section Two Hospital Billing Process |
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101 | (74) |
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Chapter 4 Patient Accounts And Data Flow |
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102 | (36) |
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Patient Accounts and Data Flow |
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103 | (6) |
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104 | (1) |
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105 | (3) |
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108 | (1) |
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109 | (2) |
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111 | (2) |
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111 | (1) |
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112 | (1) |
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Admission Evaluation Protocols (AEP) |
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112 | (1) |
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Quality Improvement Organization (QIO) |
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113 | (1) |
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113 | (7) |
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113 | (3) |
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116 | (1) |
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116 | (1) |
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116 | (2) |
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Patient's Medical Record (Chart) |
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118 | (1) |
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119 | (1) |
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Admission Summary (Face Sheet) |
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119 | (1) |
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119 | (1) |
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Medical Record Documentation |
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120 | (5) |
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121 | (1) |
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Content of the Patient's Medical Record |
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122 | (3) |
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125 | (3) |
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Common Categories of Hospital Services and Items |
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125 | (3) |
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128 | (2) |
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Charge Capture Procedures |
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128 | (1) |
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129 | (1) |
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130 | (1) |
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Health Information Management (HIM) Procedures |
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130 | (1) |
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131 | (1) |
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Accounts Receivable (A/R) Management |
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132 | (6) |
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Chapter 5 Hospital Billing Process |
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138 | (37) |
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Purpose of the Billing Process |
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140 | (1) |
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140 | (10) |
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Participating Provider Agreement (PAR) |
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141 | (2) |
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Charge Submission Requirements |
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143 | (2) |
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145 | (3) |
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Reimbursement Method Variations |
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148 | (2) |
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Charge Description Master (CDM) |
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150 | (5) |
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151 | (1) |
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Hospital Service Categories |
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151 | (2) |
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153 | (2) |
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155 | (1) |
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155 | (6) |
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156 | (1) |
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156 | (1) |
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156 | (5) |
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161 | (2) |
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161 | (1) |
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161 | (1) |
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Detailed Itemized Statement |
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161 | (2) |
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163 | (12) |
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Patient Admission and Registration |
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163 | (1) |
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164 | (1) |
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164 | (1) |
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164 | (1) |
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164 | (2) |
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166 | (1) |
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166 | (2) |
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Accounts Receivable (AR) Management |
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168 | (7) |
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175 | (176) |
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Chapter 6 ICD-9-CM Diagnosis And Procedure Coding |
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176 | (41) |
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History of Diagnosis Coding |
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177 | (3) |
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International List of the Causes of Death |
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178 | (1) |
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International Classification of Diseases (ICD) |
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178 | (1) |
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International Classification of Diseases, 9th Revision Clinical Modification (ICD-9-CM) |
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179 | (1) |
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International Classification of Diseases, 10th Revision (ICD-10) |
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179 | (1) |
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Purpose of Diagnosis Coding |
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180 | (2) |
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Diagnosis Code Data Usage |
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181 | (1) |
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Organizations Using Diagnosis Code Data |
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181 | (1) |
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Diagnosis Coding Relationships |
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182 | (5) |
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182 | (1) |
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183 | (1) |
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183 | (2) |
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185 | (2) |
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187 | (9) |
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ICD-9-CM Volume I Content |
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187 | (3) |
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ICD-9-CM Volume II Content |
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190 | (4) |
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ICD-9-CM Volume III Content |
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194 | (2) |
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ICD-9-CM Official Conventions |
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196 | (5) |
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Abbreviations and Symbols |
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196 | (2) |
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198 | (1) |
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199 | (2) |
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Steps to Coding Using ICD-9-CM |
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201 | (4) |
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201 | (1) |
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Step 2 Refer to the Alphabetic Index |
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201 | (2) |
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Step 3 Refer to the Tabular List |
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203 | (1) |
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203 | (2) |
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ICD-9-CM Official Diagnosis Coding Guidelines |
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205 | (4) |
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General Diagnosis Coding Guidelines |
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205 | (1) |
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Diagnosis Coding Guidelines for Inpatient Services |
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206 | (1) |
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Selection of the Principal Diagnosis |
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206 | (1) |
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Reporting of Additional Diagnosis |
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207 | (1) |
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Present on Admission (POA) Reporting Guidelines |
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207 | (1) |
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Diagnosis Coding Guidelines for Outpatient Services |
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208 | (1) |
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ICD-9-CM Volume III Procedure Coding Guidelines |
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209 | (8) |
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General Procedure Coding Guidelines |
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209 | (1) |
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Guidelines for Selection of Principal and Other Procedures |
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209 | (8) |
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Chapter 7 ICD-10-CM Diagnosis Coding |
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217 | (42) |
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Evolution of Diagnosis Coding |
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218 | (2) |
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International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) |
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219 | (1) |
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International Classification of Diseases, 10th Revision (ICD-10) |
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219 | (1) |
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220 | (9) |
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220 | (2) |
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222 | (1) |
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223 | (4) |
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227 | (2) |
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229 | (3) |
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229 | (1) |
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229 | (1) |
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230 | (1) |
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Organizations Using ICD-10-CM Data |
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230 | (2) |
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232 | (6) |
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Differences in ICD-10-CM versus ICD-9-CM |
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232 | (2) |
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234 | (1) |
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ICD-10-CM Mapping and Crosswalks |
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235 | (1) |
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ICD-10-CM Coordination and Maintenance Committee |
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235 | (3) |
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238 | (7) |
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Volume I Tabular List of Diseases |
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238 | (1) |
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238 | (1) |
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External Causes of Morbidity (VØØ-Y99) |
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239 | (2) |
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Factors Influencing Health Status and Contact with Health Services (ZØØ-Z99) |
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241 | (1) |
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Volume II Official Guidelines |
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242 | (1) |
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Volume III Alphabetic Index to Diseases |
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243 | (1) |
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Volume III Index - Tables |
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243 | (2) |
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Alphabetic Index to External Causes of Injury |
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245 | (1) |
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ICD-10-CM Official Conventions |
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245 | (4) |
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ICD-10-CM Official Abbreviations and Symbols |
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246 | (2) |
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ICD-10-CM Official Instructional Notes |
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248 | (1) |
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ICD-10-CM Other Official Conventions |
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249 | (1) |
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Steps to Coding Diagnoses Using ICD-10-CM |
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249 | (10) |
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249 | (1) |
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Step 2 Refer to ICD-10-CM Volume III, Alphabetic Index |
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249 | (1) |
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Step 3 Refer to ICD-10-CM Volume I, Tabular List |
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250 | (1) |
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250 | (9) |
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Chapter 8 Procedure Coding (HCPCS And ICD-10-PCS) |
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259 | (47) |
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History of Procedure Coding |
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261 | (5) |
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Health Care Common Procedure Coding System (HCPCS) |
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261 | (1) |
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International Classification of Diseases (ICD) Procedure Codes |
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262 | (1) |
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262 | (2) |
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Purpose of Procedure Coding |
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264 | (1) |
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264 | (1) |
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Procedure Code Data Usage |
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265 | (1) |
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Procedure Coding Relationships |
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266 | (5) |
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266 | (1) |
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267 | (1) |
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268 | (2) |
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270 | (1) |
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Procedure Coding System Variations |
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271 | (4) |
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271 | (1) |
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272 | (1) |
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273 | (2) |
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275 | (5) |
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HCPCS Level I CPT Content |
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276 | (2) |
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HCPCS Level I CPT Conventions and Format |
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278 | (2) |
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HCPCS Level II-Medicare National Codes |
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280 | (5) |
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280 | (2) |
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HCPCS Level II Conventions and Format |
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282 | (3) |
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International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) |
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285 | (6) |
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286 | (1) |
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Character Meanings and Definitions |
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287 | (1) |
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288 | (1) |
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289 | (2) |
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291 | (2) |
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292 | (1) |
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292 | (1) |
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ICD-10 Mapping and Crosswalks |
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292 | (1) |
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ICD-10 Coordination and Maintenance Committee |
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292 | (1) |
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Steps to Coding Using HCPCS and ICD-10-PCS |
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293 | (13) |
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Step 1 Read the Medical Record |
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293 | (1) |
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Step 2 Refer to the Alphabetic Index |
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293 | (2) |
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Step 3 Refer to the Code Sections for Code Assignment |
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295 | (1) |
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Step 4 Identify Modifier Circumstances |
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296 | (1) |
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297 | (9) |
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Chapter 9 Coding Guidelines And Applications (HCPCS, ICD-10-PCS, And ICD-10-CM) |
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306 | (45) |
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Relationship Between Billing and Coding |
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307 | (6) |
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308 | (1) |
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308 | (1) |
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309 | (4) |
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313 | (4) |
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Outpatient and Non-patient Services |
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313 | (1) |
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313 | (4) |
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ICD-10-CM Official Diagnosis Coding Guidelines |
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317 | (10) |
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ICD-10-CM General Diagnosis Coding Guidelines |
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317 | (2) |
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ICD-10-CM Outpatient Diagnosis Coding Guidelines |
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319 | (1) |
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ICD-10-CM Inpatient Diagnosis Coding Guidelines |
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320 | (1) |
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Selection of the Principal Diagnosis |
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320 | (2) |
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Reporting of Additional Diagnosis |
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322 | (1) |
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ICD-10-CM Present on Admission (POA) Reporting |
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322 | (2) |
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ICD-10-CM Coding Guidelines (Outpatient versus Inpatient) |
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324 | (3) |
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327 | (7) |
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HCPCS General Procedure Coding Guidelines |
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327 | (1) |
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HCPCS Level I CPT Coding Guidelines |
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328 | (2) |
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HCPCS Level II Medicare National Coding Guidelines |
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330 | (4) |
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ICD-10-PCS General Coding Guidelines |
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334 | (1) |
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Selection of Principal and Other Procedures |
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334 | (1) |
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ICD-10-PCS Official Coding Guidelines |
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334 | (6) |
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Body System General Guidelines B2.1a-B2.1b |
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335 | (1) |
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Root Operation General Guidelines B3.1a-B3.16 |
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335 | (2) |
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Body Part Guidelines B4.1a-B4.7.11 |
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337 | (1) |
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Approach Guidelines B5.2-B5.4 |
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338 | (1) |
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339 | (1) |
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Steps to Coding Diagnoses and Procedures |
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340 | (11) |
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341 | (10) |
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351 | (34) |
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352 | (33) |
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353 | (1) |
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353 | (4) |
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354 | (1) |
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Electronic Claim Submission |
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355 | (2) |
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357 | (2) |
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CMS-1500 Claim Form Overview |
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359 | (1) |
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359 | (1) |
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CMS-1450 (UB-04) Claim Form Overview |
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359 | (2) |
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359 | (1) |
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Section I Facility, Patient, Admission, Discharge, Occurrence, and Value Information (FL 1 to 41) |
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359 | (2) |
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Section II Charge Information (FL 42 to 49) |
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361 | (1) |
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Section III Payer, Insured, Employer, and Authorization Information (FL 50 to 65) |
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361 | (1) |
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Section IV Procedure, Diagnosis, and Provider Information (FL 66 to 81) |
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361 | (1) |
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CMS-1450 (UB-04) Instructions |
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361 | (24) |
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Section Five Health Care Payers and Reimbursement |
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385 | (120) |
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Chapter 11 Health Care Payers |
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386 | (45) |
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Types of Health Insurance Plans |
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388 | (7) |
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Traditional Fee-for-Service Plans |
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388 | (1) |
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389 | (6) |
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395 | (1) |
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395 | (2) |
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396 | (1) |
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Individual Health Insurance |
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396 | (1) |
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396 | (1) |
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Personal Injury Insurance |
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396 | (1) |
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396 | (1) |
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Workers' Compensation Insurance |
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397 | (1) |
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397 | (7) |
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397 | (1) |
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Medicare Administrative Contractor (MAC) |
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398 | (1) |
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399 | (1) |
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399 | (1) |
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399 | (1) |
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400 | (1) |
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401 | (1) |
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402 | (1) |
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402 | (1) |
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Coordination of Benefits (COB) |
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403 | (1) |
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Medicare Secondary Payer (MSP) |
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403 | (1) |
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404 | (2) |
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404 | (1) |
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404 | (1) |
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405 | (1) |
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405 | (1) |
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Coordination of Benefits (COB) |
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405 | (1) |
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Children's Health Insurance Program (CHIP) |
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406 | (1) |
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406 | (1) |
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406 | (1) |
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407 | (6) |
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407 | (1) |
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408 | (1) |
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408 | (1) |
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408 | (1) |
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|
408 | (1) |
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409 | (1) |
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410 | (1) |
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411 | (1) |
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411 | (1) |
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Coordination of Benefits (COB) |
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|
411 | (2) |
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Insurance Plan Terms and Specifications |
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413 | (18) |
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Participating Provider Agreement (PAR) |
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413 | (1) |
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413 | (1) |
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413 | (3) |
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Coordination of Benefits (COB) |
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416 | (3) |
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419 | (1) |
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419 | (1) |
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420 | (1) |
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|
420 | (1) |
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420 | (1) |
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421 | (1) |
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422 | (1) |
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422 | (1) |
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Prospective Payment Systems (PPS) Methods |
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422 | (1) |
|
|
422 | (1) |
|
|
422 | (1) |
|
|
423 | (1) |
|
|
423 | (1) |
|
|
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) |
|
|
436 | (1) |
|
|
437 | (4) |
|
Coding for MS-DRG Assignment |
|
|
441 | (3) |
|
|
444 | (1) |
|
|
444 | (1) |
|
MS-DRG Payment Calculations |
|
|
445 | (1) |
|
|
446 | (2) |
|
Outpatient Prospective Payment System (OPPS) |
|
|
448 | (5) |
|
|
449 | (1) |
|
|
450 | (1) |
|
|
451 | (2) |
|
|
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) |
|
|
455 | (1) |
|
|
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) |
|
|
459 | (1) |
|
|
460 | (1) |
|
|
460 | (1) |
|
|
461 | (1) |
|
|
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) |
|
|
471 | (4) |
|
|
472 | (1) |
|
|
472 | (1) |
|
|
473 | (1) |
|
|
474 | (1) |
|
|
475 | (2) |
|
Remittance Advice Data Elements |
|
|
475 | (1) |
|
Analyzing a Remittance Advice |
|
|
475 | (2) |
|
|
477 | (2) |
|
|
477 | (1) |
|
Third-Party Payer Payments |
|
|
477 | (1) |
|
|
478 | (1) |
|
|
479 | (3) |
|
|
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) |
|
|
486 | (1) |
|
|
486 | (2) |
|
Accounts Receivable (A/R) Procedures |
|
|
488 | (1) |
|
|
488 | (1) |
|
|
489 | (1) |
|
|
489 | (1) |
|
|
489 | (1) |
|
Credit and Collection Laws |
|
|
490 | (2) |
|
|
490 | (1) |
|
|
490 | (1) |
|
Fair Debt Collection Practices Act |
|
|
490 | (2) |
|
|
492 | (6) |
|
Prioritizing Collection Activities |
|
|
493 | (1) |
|
Patient Account Follow-Up Procedures |
|
|
493 | (1) |
|
|
493 | (1) |
|
|
493 | (1) |
|
|
494 | (1) |
|
Third-Party Payer Account Follow-Up Procedures |
|
|
494 | (1) |
|
|
495 | (1) |
|
Insurance Telephone Claim Inquiry |
|
|
496 | (1) |
|
Insurance Computer Claim Inquiry |
|
|
496 | (1) |
|
|
496 | (1) |
|
Uncollectible Patient Accounts |
|
|
497 | (1) |
|
Insurance Commissioner Inquiries |
|
|
497 | (1) |
|
|
498 | (7) |
|
Claim Determinations That Can Be Appealed |
|
|
498 | (1) |
|
Who Can Request an Appeal |
|
|
498 | (1) |
|
Time Requirement for Appeal Submission |
|
|
498 | (1) |
|
|
498 | (1) |
|
Appeal Submission Procedures |
|
|
499 | (6) |
|
|
505 | (82) |
|
|
506 | (59) |
|
|
565 | (17) |
|
|
582 | (5) |
Index |
|
587 | |