Understanding Health Insurance: A Guide to Billing and Reimbursement - 2022 Edition,
17th Edition

1. Health Insurance Specialist Career.
2. Introduction to Health Insurance and Managed Care.
3. Introduction to Revenue Management.
4. Revenue Management of the Insurance Claim Cycle, Maintaining Insurance Claim Files, and Credit and Collections.
5. Legal Aspects of Health Insurance and Reimbursement.
6. ICD-10-CM Coding.
7. CPT Coding.
8. HCPCS Level II Coding.
9. CMS Reimbursement Methodologies.
10. Coding Compliance, Clinical Documentation Improvement, and Coding for Medical Necessity.
11. CMS-1500 and UB-04 Claims.
12. Commercial Insurance.
13. BlueCross BlueShield.
14. Medicare.
15. Medicaid.
16. TRICARE.
17. Workers’ Compensation.
Appendices.
Bibliography.
Glossary.
Index.

• Michelle Green

  Michelle Green has been a SUNY Distinguished Teaching Professor in the health information technology department at Mohawk Valley Community College in Utica, New York, since 2017. Ms. Green held the position of SUNY Distinguished Teaching Professor in the physical and life sciences department at the State University of New York, College of Technology for more than 30 years. An active member of the American Academy of Professional Coders (AAPC) and American Health Information Management Association (AHIMA), Ms. Green has been recognized both for her excellence in teaching and for her significant contributions to the health information management profession. She has earned numerous awards, including the State University of New York Chancellor’s Award for Excellence in Teaching, Alfred State College’s Alumni Association Teacher of the Year, Who’s Who Among America’s Teachers and AHIMA’s FORE Triumph Educator Award. Ms. Green is a registered health information administrator (RHIA), a fellow of the American Health Information Management Association (FAHIMA) and a certified procedural coder (CPC). She earned an M.P.S. degree from Alfred University and a B.S. from Daemen College. Ms. Green has authored three popular textbooks related to coding, revenue management and health information management.

• ANNUAL UPDATES ADDRESS THE LATEST DEVELOPMENTS IN HEALTH INSURANCE AND MEDICAL BILLING TODAY. In addition to updating content throughout, this edition has consolidated and streamlined information for a clearer presentation. Chapter 2, Introduction to Health Insurance, now combines information from previous brief Chapters 2 and 3. Information in former Chapter 4 is now separated into Chapter 3, Introduction to Revenue Management, and Chapter 4, Revenue Management of the Insurance Claim Cycle, Maintaining Insurance Claim Files, and Credit and Collections.

• UPDATED INSTRUCTIONS GUIDE STUDENTS THROUGH ACCURATELY COMPLETING TODAY'S INSURANCE CLAIMS. The author has carefully updated all instructions for completing insurance claims within Chapters 11-17. Revisions reflect the latest requirements and prepare students to seamlessly transition their skills from the academic to professional environment.

• CONTENT ON REVENUE MANAGEMENT IS DIVIDED INTO TWO CHAPTERS 3 AND 4 FOR CLEARER PRESENTATION. Chapter 3 introduces new material on accounts payable; copayment; discharged not final billed (DNFB), discharged not final coded (DNFC); facility, institutional and professional billing; and single-path coding. Content also addresses emancipated minors, suspended claims, third-party payer review, independent external reviewer (or Medicare-qualified independent contractor), fragmentation and skip tracing. The review has three new assignments. Chapter 4 covers the claim cycle, files, credit and collection.

• EXPANDED COVERAGE OF THE NATIONAL CORRECT CODING INITITATIVE (NCCI) PROGRAM APPEARS IN CHAPTER 5. Additional new content about the NCCI program provides clarification about its use. In addition, the Chapter 5 review contains two new assignments addressing HIPAA fraud and abuse and privacy and security rules.

• UPDATES TO ICD-10-CM CONTENT REFLECT THE LATEST CHANGES AND DEVELOPMENTS. This edition highlights all updated ICD-10-CM guidelines and codes and applicable general coding guidelines within outpatient coding guidelines using shaded boxes. This shading bring special attention to the most recent changes.

• NEW COVERAGE HIGHLIGHTS THE LATEST CPT® CHANGES. The author has incorporated the most recent CPT coding guidelines and codes throughout this edition. Coding Step 7 within the Review Appendix B in the CPT coding manual was added to guide readers. In addition, new content clarifies how to enter CPT codes on the CMS-1500 claim, based on highest to lowest reimbursement and the global period.

• UPDATES TO CONTENT IN CHAPTERS 6-17 INTEGRATE NEW AND REVISED ICD-10-CM, CPT® AND HCPCS LEVEL II CODES. All explanations, exercises and activities within these chapters reflect the latest changes and most up-to-date rules and regulations and their impact on today's coding systems.

• CHAPTER 9 PROVIDES NEW CONTENT RELATED TO NEVER EVENTS AND ASC/HOSPITAL VALUE-BASED PURCHASING. New material highlights Never Events, ambulatory surgery center value-based purchasing and imagery that summarizes VBP programs. New explanations clarify hospital value-based purchasing. In addition, the chapter review contains three new assignments: Data Analytics for Medicare Part B Reimbursement, Interpreting Medicare Status Indicators and Procedure Discounting Data for Ambulatory Payment Classifications, and Interpreting Medicare-Severity Diagnosis-Related Groups Data.

• LEARNING DESIGN METHODOLOGY WITH CLEAR OBJECTIVES GUIDES READER UNDERSTANDING. This edition's learning design methodology clearly maps chapter content to both major topics and well-defined learning objectives to keep students focused and progressing.

• UPDATED CONTENT ADDRESSES THE LATEST DEVELOPMENTS IN THE FIELD TODAY. Revised chapter content throughout this edition highlights the latest updates in revenue management, reimbursement methods, health insurance processing and medical coding.

• ONLINE TOOLS ASSIST IN MASTERY OF ICD-10-PCS CODING AND GUIDELINES. The latest content about ICD-10-PCS coding and official guidelines are located on the student online companion website with a variety of application exercises to strengthen coding skills. Answer keys are conveniently found on the password-protected instructor's companion website.

• UPDATED INSTRUCTIONS INCORPORATE THE LATEST CHANGES IN COMPLETING TODAY'S INSURANCE CLAIMS. Clear instructions for completing CMS-1500 insurance claims reflect today's requirements and the latest changes. Updates in instructions appear throughout the printed book and SimClaim software as well as within the answer keys in the instructor’s manual.

• REVIEW QUESTIONS REQUIRE PAYMENT CALCULATIONS TO HELP STRENGTHEN SKILLS. Students gain important practice in calculating insurance or Medicare payments, co-payments and coinsurance as they complete this edition's review questions. The author has incorporated these requirements to ensure students have the practice necessary to master these important skills.

• VARIETY OF NEW AND REVISED REVIEW QUESTIONS ENSURE STUDENT UNDERSTANDING. Revised multiple-choice review questions more accurately assess student comprehension, while additional questions check student understanding of the latest key concepts and applications.

• ONLINE SIMCLAIM SOFTWARE WITHIN MINDTAP PROVIDES PROFESSIONAL HANDS-ON PRACTICE. Case studies in the SimClaim software present billing data and patient histories. Students complete data entry of CMS-1500 claims and receive immediate feedback. Clear instructions for using SimClaim software appear at the end of the printed book's preface for user convenience.

• KEY TERMS, SECTION HEADINGS AND LEARNING OBJECTIVES ORGANIZE AND DIRECT LEARNING. Students can use the clear learning objectives at the beginning of each chapter as a self-test for checking comprehension and mastering chapter content. In addition to well organized content, boldfaced key terms appear throughout each chapter to help students master the technical vocabulary associated with claims processing.

• CODING AND CLAIMS COMPLETION EXERCISES ALLOW STUDENTS TO PRACTICE CONCEPTS AS THEY PROGRESS. Students complete coding exercises throughout Chapters 6, 7, 8 and 10 and complete claims completion exercises in Chapters 11-17. Answers to all of these exercises are available in the instructor’s manual for your convenience in checking student work.

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