...UNDERSTANDING MEDICAL INSURANCE KEY TERMS Step 1 S te St ep 10 Follow up payments and collections Preregister patients p2 Establish financial responsibility St ep 3 S te p 9 Generate patient statements Check in patients Monitor payer adjudication Review coding compliance St ep 8 S te Check out patients Review billing compliance p7 St ep 5 S tep 6 Learning Outcomes After studying this chapter, you should be able to: 1.1 Explain how healthy practice finances depend on correctly accomplishing administrative tasks in the medical office. 1.2 Compare coinsurance and copayment requirements for health Copyright © 2014 The McGraw-Hill Companies plan benefits. 1.3 Identify the key steps in the medical billing cycle. 1.4 Discuss the impact of electronic health records on clinical and billing workflow. 1.5 Evaluate the importance of professional certification and of medical liability insurance for career advancement. S te p4 Medical Billing Cycle Prepare and transmit claims 1 accounts payable (AP) accounts receivable (AR) benefits cash flow certification coding coinsurance copayment covered services deductible diagnosis documentation electronic claim (e-claim) electronic health record (EHR) fee-for-service health care claim health information technology (HIT) health plan indemnity plan managed care managed care organization (MCO) medical assistant ...
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...the Physician Office CHAPTER OUTLINE Patient Flow in the Physician Practice Step 1. Pre-Visit: Appointment Scheduling and Information Collection Step 2. Patient Check-in and Payment Collection Step 3. Rooming and Measuring Vital Signs Patient Examination and Documentation Step 4. Patient Checkout Step 5. Post-Visit: Coding and Billing Post-Visit: Reviewing Test Results Coding and Reimbursement in Electronic Health Records Computer-Assisted Coding Clinical Tools in the Electronic Health Record Decision-Support Tools Tracking and Monitoring Patient Care Screening for Illness or Disease Identifying at-Risk Patients Managing Patients with Chronic Diseases Improving the Quality and Safety of Patient Care with Evidence-Based Guidelines E-Prescribing and Electronic Health Records Keeping Current with Electronic Drug Databases Increasing Prescription Safety Saving Time and Money LEARNING OUTCOMES After completing this chapter, you will be able to define key terms and: 1. 2. 3. 4. 5. 6. 7. 8. 9. List the five steps of the office visit workflow in a physician office. Discuss the advantages of pre-visit scheduling and information collection for patients and office staff. Describe the process of electronic check-in. Explain how electronic health records make documenting patient exams more efficient. Explain what occurs during patient checkout. Explain what two events take place during the post-visit step of the visit workflow. Describe the advantages of computer-assisted coding. List three decision-support...
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...0 3 0 Electronic Health Records in the Physician Office CHAPTER OUTLINE Patient Flow in the Physician Practice Step 1. Pre-Visit: Appointment Scheduling and Information Collection Step 2. Patient Check-in and Payment Collection Step 3. Rooming and Measuring Vital Signs Patient Examination and Documentation Step 4. Patient Checkout Step 5. Post-Visit: Coding and Billing Post-Visit: Reviewing Test Results Coding and Reimbursement in Electronic Health Records Computer-Assisted Coding Clinical Tools in the Electronic Health Record Decision-Support Tools Tracking and Monitoring Patient Care Screening for Illness or Disease Identifying at-Risk Patients Managing Patients with Chronic Diseases Improving the Quality and Safety of Patient Care with Evidence-Based Guidelines E-Prescribing and Electronic Health Records Keeping Current with Electronic Drug Databases Increasing Prescription Safety Saving Time and Money LEARNING OUTCOMES After completing this chapter, you will be able to define key terms and: 1. 2. 3. 4. 5. 6. 7. 8. 9. List the five steps of the office visit workflow in a physician office. Discuss the advantages of pre-visit scheduling and information collection for patients and office staff. Describe the process of electronic check-in. Explain how electronic health records make documenting patient exams more efficient. Explain what occurs during patient checkout. Explain what two events take place during the post-visit step of the...
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...Chapter 1 Introduction to Professional Billing and Coding Careers MULTIPLE CHOICE 1. The percentage of all healthcare providers who are physicians and nurses is: a. 25%. b. 40%. c. 50%. d. 60%. Answer: b EMPLOYMENT DEMAND 2. The percentage of all healthcare providers who are allied health professionals is: a. 25%. b. 40%. c. 50%. d. 60%. Answer: d EMPLOYMENT DEMAND 3. The increased demand for medical billers, medical office assistants, and medical coders can be attributed to: a. the growth of managed care. b. physician practices having more responsibility for filing claims. c. the need for additional staff to file claims and work to obtain timely payment. d. all of the above. Answer: d EMPLOYMENT DEMAND 4. All of the following changes were a result of managed care EXCEPT: a. physicians having to wait 30 days or longer for payment. b. physicians having more responsibility for filing claims. c. patients having to pay for services when rendered. d. physicians having to add to their staff. Answer: c EMPLOYMENT DEMAND 5. Before the 1970s, a physician’s practice would grow based on: a. advertising and referrals. b. managed care contracts. c. consultations. d. hospital affiliations. Answer: a EMPLOYMENT DEMAND 6. Before the 1970s, a solo practice included all of the following staff members EXCEPT: a. physician. b. nurse. c. certified medical biller. d. receptionist. Answer: c EMPLOYMENT DEMAND 7. Managed care is...
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...Standards Lulett Baldwin Grand Canyon University: Health Information Technology and Management HCA-360 September 9, 2012 Chapter Questions 12-1. Define the following terms: a. Medicine – The study and treatment of general diseases or those affecting the internal parts of the body, especially those not usually requiring surgical intervention. (MediLexicon International, LTD, 2012). b. Medical Informatics (MI) – The field of information science concerned with the analysis and dissemination of medical data through the application of computers to various aspects of health care and medicine (TheFreeDictionary, 2012). c. Standards – An acknowledged measure of comparison for quantitative or qualitative value; a criterion. Widely recognized as a model of authority or excellence (TheFreeDictionary, 2012). d. HIPAA – Health Insurance Portability and Accountability Act, the Privacy Rule was enacted on August 21, 1996, by the U.S Congress. This Act was instituted to protect the freedom, security, privacy, and confidentiality of individuals (Tan & Payton 2010). 12-2. What are data standards? Discuss the usefulness of these standards to implementing HMIS? Answer: HIPAA was enacted to expedite the development of data standards. Healthcare professionals have identified that the root cause of inhibition to sharing medical information electronically is the lack of comprehensive data standards. The need for data standards falls into three categories:...
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...regarding the diseases and conditions that effect world’s population has become a high priority. Due to this evolution, the ICD-9-CM system has become outdated and can no longer accommodate our needs. Effective October 1, 2014 the United States will implement ICD-10-CM/PCS for use across the nation. Initially we will cover ICD-10-CM and then address ICD-10-PCS. ICD-10-CM is the classification system to be utilized to record diagnoses identified and treated in both the acute care setting as well as the ambulatory setting. There are various differences between ICD-9-CM and ICD-10-CM and we will highlight several of those differences today. One difference between the two coding classification systems is the number of chapters. ICD-10-CM consists of twenty-one chapters as compared to the seventeen chapters in ICD-9-CM. There are approximately 68,000 diagnostic codes in ICD-10-CM as opposed to the 14,000 in ICD-9-CM (DeVault, Barta, & Endicott, 2012). The length and structure of the codes in ICD-10-CM vary greatly from ICD-9-CM. We have been accustomed to codes being from three to five characters in length. In ICD-10-CM codes can be up to seven characters in length and are alphanumeric in structure. The addition of a seventh character is used for obstetrics, injuries and external causes. ICD-10-CM also uses a...
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...TABLE OF CONTENTS Execusive Summary # INTRODUCTION # CHAPTER 2 # SECTION 2.1 # SECTION 2.2 # SUBSECTION 2.2.A # SUBSECTION 2.2.B # SUBSECTION 2.2.C # SECTION 2.3 # CHAPTER 3 # SECTION 3.1 # SECTION 3.2 # SECTION 3.3 # SUBSECTION 3.3.A # SUBSECTION 3.3.B # SUBSECTION 3.3.C Excusive Summary Numerous healthcare organizations are investing in the use of Epic Electronic Record (EHR) solutions to improve quality of patient care and efficiency. With the growing reliance on digital records for everything from patient test results to medical records to billing and HIPPA reporting, high level of availability Epic HER environment has never been more important. Epic creates and provides integrated software to health care organizations so they can take better care of patients by improving outcomes, enhancing the patient’s experience, and supporting research. All of Epic’s applications are built on a single database, providing an integrated solution that supports patient care and continuity throughout hospitals, clinics, and physician offices. Using these applications, health care organizations and professionals can access the appropriate patient information instantly whenever and wherever needed. Epic is privately held health care software company. In 1979 it was founded by Judith Faulkner. The company headquarters was in Madison, Wisconsin, but in 2005 the company moved to...
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...The 13,000 codes that are a maximum of 5 characters, made some of the chapters without the capability to add new codes because they were full. Because of this, new codes had to be assigned to different chapters, which made it hard to locate all of the available codes. With the introduction of ICD-10CM having increased character length, it will expand the number of codes available for use. This will also make it less likely that chapters will run out of codes in the future. Also, the ICD-9 had unspecified diagnosis codes whereas the new ICD-10CM/PCS has very detailed codes. An example would be with ICD-9 a person treated for a burn on her left arm, wont distinguish that the burn was on her left arm, just arm. If she were to come back at a later date with another burn to the same arm, the code would be the same and it would not show that it wasn't the initial encounter. An example of the new ICD-10 code sets, the characters in the code would identify right versus left and also an initial...
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...retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. HIBCC ® and HIN® System are trademarks of the Health Industry Business Communications Council. ISBN: 0-9725371-2-0 Table of Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi Chapter 1: The Basics What is a bar code? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 How can you benefit from bar coding? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Inventory management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...
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...EMPLOYEES | | |file involve) |HEALTH CARE PERSONNEL | | |Manufacturing (Equipment/Supplies) |Example: |Example: |Example: | | |Health Care manufacturing deals with the|- Medical supply/DME company owner or |Health Care personnel can work in | | |making of consumer products that help |employee |settings such as hospitals, durable| | |individuals deal with health care issues|- Medical supplies sales or sales |medical equipment (DME) or medical | | |such as durable medical equipment (DME) |assistant |supply companies, home care, long-term | | |and medical supplies. |- Health care...
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...Principles of Healthcare Reimbursement Anne B. Casto, RHIA, CCS Elizabeth Layman, PhD, RHIA, CCS, FAHIMA Copyright ©2006 by the American Health Information Management Association. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, photocopying, recording, or otherwise, without the prior written permission of the publisher. ISBN 1-58426-070-X AHIMA Product No. AB202006 Ken Zielske, Director of Publications Susan Hull, MPH, RHIA, CCS, CCS-P, Technical Reviewer Marcia Loellbach, MS, Project Editor Elizabeth Lund, Assistant Editor Melissa Ulbricht, Editorial/Production Coordinator All information contained within this book, including Web sites and regulatory information, was current and valid as of the date of publication. However, Web page addresses and the information on them may change or disappear at any time and for any number of reasons. The user is encouraged to perform his or her own general Web searches to locate any site addresses listed here that are no longer valid. AHIMA strives to recognize the value of people from every racial and ethnic background as well as all genders, age groups, and sexual orientations by building its membership and leadership resources to reflect the rich diversity of the American population. AHIMA encourages the celebration and promotion of human diversity through education, mentoring, recognition, leadership, and other programs. American...
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...Part II POLICIES AND PROCEDURES FOR THE PHYSICIANS’ INJECTABLE DRUG LIST GEORGIA DEPARTMENT OF COMMUNITY HEALTH DIVISION OF MEDICAL ASSISTANCE PLANS Published October 1, 2013 PREFACE The Physicians’ Injectable Drug List (PIDL) manual contains basic information regarding Georgia’s Fee for Service (FFS) Medicaid and PeachCare for Kids programs and should be used in conjunction with Policies and Procedures Manual for Medicaid and PeachCare for Kids Part I, Part II Policies and Procedures Manual for Physician Services, and other applicable program manuals. We urge you and your office staff to familiarize yourselves with the contents of this manual and refer to it when questions arise. Use of the manuals will assist in the elimination of misunderstandings concerning the coverage levels and billing procedures that can result in delays of claims processing or payments, inaccuracies and/or denials. The PIDL is reviewed and updated quarterly, it is re-priced annually. Drugs that are not re-priced by the manufacturer or are no longer manufactured, or obsolete may not be re-priced or changed— refer to the Schedule of Maximum Allowable Payments (Appendix A) in this manual. For quality purposes, the PIDL is periodically purged of drugs with no or low (fewer than 50 units of service annually) utilization over a three (3) year period; except for orphan drugs and certain chemotherapeutic agents. Requests for coverage of purged drugs will be considered on a case-bycase...
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... Healthcare services (ex. hospitals), Health insurance (makes most of the payments to the health service providers), Medical equipment and supplies (maker of medical/diagnostic equipment), Pharmaceuticals and biotechnology (develop/market drugs/therapeutics), and "other" (which includes consulting, educational, government, and research agencies) b. What is meant by the term healthcare finance as used in this book? Healthcare Finance consists of both the accounting (which creates and provides useful operations and financial status information to interested internal and external parties for assessing financial and operation performance) and financial management (provides the theory, concepts, and tools necessary to help managers make better financial decisions) for the healthcare sector of the economy. c. What are the two broad areas of healthcare finance? Accounting and financial management (aka Corporate Finance) d. Why is it necessary to have a book on healthcare finance as opposed to a generic finance book? Healthcare services are dominated by both private and governmental not-for-profit corporations, which differ from investor-owned businesses (learned in a generic finance book) due to the majority of payments being made are from third-party payers (e.g., employers, commercial insurance companies, government programs). 2. What is the difference between a business and a pure charity? A pure charity is a budgetary organization in that the...
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...Fundamentals of Law for Health Informatics and Information Management Second Edition Check Your Understanding Chapter Answers CHAPTER 1 Check Your Understanding 1.1 1. A hybrid record is refers to record that is totally electronic. False 2. An electronic health record can be managed across more than one healthcare organization. True 3. Confidentiality refers to the right to be left alone. False 4. HITECH widens the scope of privacy and security protections under HIPAA. True 5. Privileged communication is a legal concept designed to protect the communication between two parties. True Check Your Understanding 1.2 1. Ownership of a health record generated by a doctor on a patient belongs to the patient. False 2. A custodian of records is responsible for certifying that a record is what it purports to be. True 3. When a patient refuses treatment he or she is exercising the ethical principle of beneficence. False 4. In a malpractice case, a professional code of ethics may be used as a benchmark for what should be acceptable practice by a healthcare professional. True 5. The ethical principle of nonmaleficence refers to making sure rules are fairly and consistently applied to all. False CHAPTER 2 Check Your Understanding 2.1 1. Private law defines rights and duties between individuals and the government. False 2. Statutes are enacted by legislative bodies. True 3. Administrative law is created by court decisions...
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...CHAPTER 22 Banking Services and Procedures Vocabulary Review Fill in the blanks with the correct vocabulary terms from this chapter. 1. Judy was unaware that checks were processed through at her bank. before they arrived 2. Because Alicia was the person who wrote the check, she was considered to be the . 3. When the Blackburn Clinic purchased the ultrasound machine, they paid $10,000 toward the so that they would be charged less interest. 4. Pamela wrote a check to Samantha, so Pamela is the . and Samantha is the 5. The of a check is the person who is presenting it for payment and may not be the person named as the payee. 6. Grace studied the , which is a series of laws that regulates sales of goods, commercial paper, secured transactions in personal property, and many aspects of banking. 7. First National Bank is considered the accounts. for Dr. Lupez’ business checking . 8. Instruments that are legally transferable to another party are considered 9. Rhonda made several and order supplies. from the clinic checking account to pay monthly bills 10. As soon as the monthly bank statement arrives, Rhonda does a to make certain that the statement and checkbook balance are in agreement. Copyright © 2007, 2003 by Saunders, an imprint of Elsevier Inc. All rights reserved. 283 284 22 BANKING SERVICES AND PROCEDURES Skills and Concepts Part I: Short Answer Questions Provide the answers to the questions in the blanks below. 11. List the four requirements...
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