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Fordney's Medical Insurance and Billing
- 17th Edition - August 7, 2024
- Author: Linda M. Smith
- Language: English
- Paperback ISBN:9 7 8 - 0 - 4 4 3 - 1 0 8 7 8 - 5
- eBook ISBN:9 7 8 - 0 - 4 4 3 - 1 1 0 4 5 - 0
Gain the skills you need to succeed in insurance coding and billing! Fordney’s Medical Insurance and Billing, 17th Edition helps you master the insurance billing specialist’s rol… Read more
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Request a sales quoteGain the skills you need to succeed in insurance coding and billing! Fordney’s Medical Insurance and Billing, 17th Edition
helps you master the insurance billing specialist’s role and responsibilities in areas such as diagnostic coding, procedural coding, HCPCs coding, medical documentation, billing, and collection. Using clear explanations, this book covers all types of insurance coverage commonly encountered in hospitals, physicians’ offices, and clinics. Step-by-step guidelines lead you through the submission of electronic claims and paper claims, as well as the job search and professional advancement. Written by coding specialist and educator Linda M. Smith, this market-leading text is a complete guide to becoming an efficient insurance billing specialist.
helps you master the insurance billing specialist’s role and responsibilities in areas such as diagnostic coding, procedural coding, HCPCs coding, medical documentation, billing, and collection. Using clear explanations, this book covers all types of insurance coverage commonly encountered in hospitals, physicians’ offices, and clinics. Step-by-step guidelines lead you through the submission of electronic claims and paper claims, as well as the job search and professional advancement. Written by coding specialist and educator Linda M. Smith, this market-leading text is a complete guide to becoming an efficient insurance billing specialist.
- NEW HCPCs Coding chapter covers ambulance billing, supply billing, and certificates of medical necessity.
- NEW! Content on professionalism includes customer service, conflict management, diversity awareness, leadership, and other competencies to help you become an effective, engaged, and highly functioning employee.
- NEW! Additional content on medical decision making helps you select the appropriate evaluation and management codes under the current documentation guidelines.
- NEW! Additional examples of CMS claims include those from Blue Shield and Automobile Insurance.
- NEW! Updates to credentialing include those specific to Medicare, Medicaid, and Workers’ Compensation.
- Coverage of medical documentation, diagnostic coding, and procedural coding provides you with the foundation and skills needed to work in a physician’s office as well as ambulatory and inpatient settings.
- Coverage of the role and responsibilities of the insurance billing specialist emphasizes advanced job opportunities and certification.
- Chapter on HIPAA compliance as well as Compliance Alerts highlight important HIPAA compliance issues and the latest regulations.
- Step-by-step procedures detail common responsibilities of the insurance billing specialist and coder.
- Key terms and abbreviations are defined and emphasized, reinforcing your understanding of new concepts and terminology.
- Color-coded icons denote and clarify information, rules, and regulations for each type of payer.
- Insights From The Field includes more interviews with experienced insurance billing specialists, providing a snapshot of their career paths and offering advice to the new student.
- Scenario boxes help you apply concepts to real-world situations.
- Quick Review sections summarize chapter content and also include review questions.
- Student Software Challenge on the Evolve website allows you to practice filling out interactive CMS-1500 forms.
- Cover image
- Title page
- Table of Contents
- Copyright
- About the Author
- Acknowledgments
- Contributor and Reviewers
- Welcome to the 17th Edition
- Purpose
- Why Is This Book Important to the Profession?
- Who Will Benefit From This Book?
- Content
- Organization
- Ancillaries
- Summary
- Unit 1. Career Role and Responsibilities
- 1. Role of an Insurance Billing Specialist
- Background of Insurance Claims, Coding, and Billing
- Role of The Insurance Billing Specialist
- Professionalism
- Scope of Practice and Liability
- Future Challenges
- 2. Privacy, Security, and HIPAA
- Health Insurance Portability And Accountability Act
- Transactions and Code Sets
- National Identifiers
- The Privacy Rule: Confidentiality and Protected Health Information
- Patients’ Rights Under HIPAA
- The Security Rule: Administrative, Technical, and Physical Safeguards
- Health Information Technology for Economic and Clinical Health Act
- HIPAA Updates
- Consequences of Noncompliance with HIPAA and Hitech
- Examples of Recent HIPAA Violations
- Organization and Staff Responsibilities in Protecting Patient Rights
- 3. Compliance, Fraud, and Abuse
- Compliance Defined
- Fraud and Abuse Laws
- Compliance Audits and Oversight
- Compliance Programs
- OIG Compliance Program Guidelines
- What to Expect from The Health Care Organization
- Unit 2. Introduction to Health Insurance
- 4. Basics of Health Insurance
- History of Health Insurance in the United States
- Health Care Reform
- Legal Principles of Insurance
- The Insurance Policy
- Choice of Health Insurance
- Types of Health Insurance
- Handling and Processing Insurance Claims
- Life Cycle of an Insurance Claim
- Keeping Up to Date
- 5. The Blue Plans, Private Insurance, and Managed Care Plans
- Private Health Insurance
- Managed Care
- Managed Care Systems
- Utilization Management
- Management of Insurance Plans
- Revenue Cycle Management
- 6. Medicare
- Background
- Policies and Regulations
- Additional Insurance Programs
- Utilization and Quality Control
- Program Fundamentals
- Medicare Reimbursement
- Claim Submission
- After Claim Submission
- 7. Medicaid and Other State Programs
- MEDICAID
- MEDICAID PROGRAMS
- MEDICAID ELIGIBILITY
- MEDICAID BENEFITS
- MEDICAID MANAGED CARE
- ACCEPTING MEDICAID PATIENTS
- CLAIMS PROCEDURES
- AFTER CLAIMS SUBMISSION
- 8. TRICARE and Veterans Health Care
- Tricare
- History of Tricare
- Tricare Authorized Providers
- Tricare Health Plans
- Veterans Health Administration Program
- Tricare and Veterans Health Administration Claims Procedures
- After Claim Submission
- 9. Workers’ Compensation, Automobile, and Liability Insurance
- Workers’ Compensation Defined
- Workers’ Compensation Insurance Programs
- Eligibility
- Federal and State Laws
- Types of State Compensation Benefits
- Types of State Workers’ Compensation Claims
- Fraud and Abuse
- Legal Situations
- Medical Record Management
- Reporting Requirements
- Claim Submission
- Automobile Insurance
- Liability Insurance
- 10. Disability Income Insurance and Disability Benefit Programs
- Disability Income Insurance Defined
- History
- Disability Income Insurance Policies
- Federal Disability Programs
- State Disability Insurance
- Disability Income Claims Submission Guidelines
- Unit 3. Documentation and Coding for Professional Services
- 11. Medical Documentation and the Electronic Health Record
- The Documentation Process
- General Principles of Health Record Documentation
- Documentation Guidelines for Diagnoses
- Documentation Guidelines for Evaluation and Management Services
- Documentation Guidelines for Surgical Services
- Documentation Guidelines for Anesthesia Services
- Documentation Guidelines for Radiology Services
- Documentation Guidelines for Pathology and Laboratory Services
- Documentation Guidelines for Medical Services
- Release and Retention of Records
- Abstracting from Health Records
- Review and Audit of Health Records
- 12. ICD-10-CM Coding
- Diagnosis Coding Overview
- International Classification of Diseases
- Assigning a Diagnosis Code
- Organization and Format of ICD-10-CM
- Official Guidelines for ICD-10-CM
- General Coding Guidelines
- Chapter-Specific Coding Guidelines
- Diagnostic Coding and Reporting for Outpatient Services
- Coding and Reporting Guidelines for Inpatient Hospital Care
- Computer-Assisted Coding
- The Future of Diagnosis Coding
- 13. CPT Coding
- UNDERSTANDING THE IMPORTANCE OF PROCEDURAL CODING SKILLS
- LEVEL I: CURRENT PROCEDURAL TERMINOLOGY CODES
- CURRENT PROCEDURAL TERMINOLOGY CONTENT AND FORMAT
- Evaluation and Management Services (99202 to 99499)
- ANESTHESIA SERVICES (00100 to 01999)
- Surgery Guidelines
- RADIOLOGY SERVICES (70010 to 79999)
- PATHOLOGY AND LABORATORY SERVICES (80047 to 89398)
- MEDICINE (90281 to 99607)
- CODE MODIFIERS
- CORRECT CODING EDITS AND PRACTICES
- METHODS OF PAYMENT
- 14. HCPCS Level II Coding
- Healthcare Common Procedure Coding System
- HCPCS Level II Code Categories
- Modifiers
- Reimbursement for HCPCS Codes
- Unit 4. Claims Submission in the Medical Office
- 15. The Paper Claim CMS 1500
- The Paper Claim CMS 1500
- Types of Submitted Claims
- Abstracting from Medical Records
- Basic Guidelines for Submitting a Health Insurance Claim Form (CMS 1500)
- Common Reasons Why Claim Forms are Delayed or Rejected
- Additional Claim Submission Errors
- Claim Completion Guidelines
- Instructions for Completing the Health Insurance Claim Form (CMS 1500)
- 16. The Electronic Claim
- THE ELECTRONIC CLAIM
- TRANSACTION AND CODE SET REGULATIONS: STREAMLINING ELECTRONIC DATA INTERCHANGE
- ELECTRONIC STANDARD HIPAA 837P
- STANDARD UNIQUE IDENTIFIERS
- BUILDING THE ELECTRONIC CLAIM
- FOLLOW-UP OF ELECTRONIC CLAIMS PROCESSING
- TRANSMISSION REPORTS
- Unit 5. Revenue Cycle Management
- 17. Receiving Payments and Insurance Problem-Solving
- Revenue Cycle Management
- Claim Policy Guidelines
- Explanation of Benefits
- Claim Management Techniques
- Claim Inquiries
- Review and Appeals Process
- State Insurance Commissioner
- Claim Denial Management
- 18. Collection Strategies
- Collection Strategies
- Patient Education
- Fees
- Collecting Fees
- Self-Pay Billing
- The Collection Process
- Special Collection Issues
- Collection Controls
- Unit 6. Health Care Facility Billing
- 19. Introduction to Health Care Facilities and Ambulatory Surgery Centers
- History of Health Care Facilities
- Types of Health Care Facilities
- Regulation of Health Care Facilities
- Inpatient, Outpatient, and Nonpatient Services
- Revenue Cycle in Health Care Facilities
- Reimbursement Methodologies
- Quality in Health Care Facilities
- 20. Billing for Health Care Facilities
- Introduction to Facility Billing
- Outpatient and Inpatient Diagnosis Coding Guidelines
- Introduction to Inpatient Facility Procedure Coding
- CMS 1450/Uniform Bill UB-04
- Unit 7. Employment
- 21. Seeking a Job and Attaining Professional Advancement
- Employment Opportunities
- Professional Organizations
- Self-Employment
- Attaining Professional Advancement
- Key Abbreviations
- Glossary
- INDEX
- Language: English
- Edition: 17
- Published: August 7, 2024
- Imprint: Saunders
- Paperback ISBN: 9780443108785
- eBook ISBN: 9780443110450
LS
Linda M. Smith
Linda M Smith is the author of Fordney’s Medical Insurance, 16e and its accompanying workbook and online course. She has revised 3 editions of HIPAA Online. She has had over 40 years of experience in the healthcare industry as a business manager and is a Certified Professional Coder (CPC). She has also earned the credentials of E/M Specialist (CEMC) and is an approved Professional Medical Coding Curriculum Instructor (CPC-I) through the American Academy of Professional Coders (AAPC). Linda provides training privately to local organizations and is an instructor with various business and technical schools. She and her associates provide training in the areas of medical ethics, medical terminology, anatomy and physiology, and medical coding and billing. They provide continuing education workshops for the organizations mentioned above.
Affiliations and expertise
Training and Consulting, MedOffice Resources, Greene, NY, USA