Medical Insurance A Revenue Cycle Process Approach.

Eighth Edition

Joanne D. Valerius, RHIA, MPH Oregon Health & Science University

Nenna L. Bayes, AAS, BBA, M.Ed., CPC Ashland Community and Technical College, Retired

Cynthia Newby, CPC, CPC-P

Amy L. Blochowiak, MBA, ACS, AIAA, AIRC, ARA, FLHC, FLMI, HCSA, HIA, HIPAA, MHP, PCS, SILA-F

Northeast Wisconsin Technical College

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MEDICAL INSURANCE: A REVENUE CYCLE PROCESS APPROACH, EIGHTH EDITION

Published by McGraw-Hill Education, 2 Penn Plaza, New York, NY 10121. Copyright ©2020 by McGraw-Hill Education. All rights reserved. Printed in the United States of America. Previous editions ©2017, 2014, and 2012. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written consent of McGraw-Hill Education, including, but not limited to, in any network or other electronic storage or transmission, or broadcast for distance learning.

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ISBN 978-1-259-60855-1 (bound edition) MHID 1-259-60855-7 (bound edition) ISBN 978-1-260-48911-8 (loose-leaf edition) MHID 1-260-48911-6 (loose-leaf edition)

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Library of Congress Cataloging-in-Publication Data

Names: Valerius, Joanne, author. Title: Medical insurance : a revenue cycle process approach / Joanne D.  Valerius, RHIA, MPH [and three others]. Description: Eighth edition. | New York, NY : McGraw-Hill Education, [2020] Identifiers: LCCN 2018043777| ISBN 9781259608551 (alk. paper) | ISBN  1259608557 (alk. paper) Subjects: LCSH: Health insurance. | Health insurance claims—United States. |  Health insurance—United States. Classification: LCC HG9383 .B39 2020 | DDC 368.38/2014—dc23 LC record available at https://lccn.loc.gov/2018043777

The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a website does not indicate an endorsement by the authors or McGraw-Hill Education, and McGraw-Hill Education does not guarantee the accuracy of the information presented at these sites.

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Preface ix

Part 1 WORKING WITH MEDICAL INSURANCE AND BILLING 1

Chapter 1 Introduction to the Revenue Cycle 2

 

Chapter 3 Patient Encounters and Billing Information 71

Part 2 CLAIM CODING 105

Diagnostic Coding: ICD-10-CM 106

Procedural Coding: CPT and HCPCS 137

Visit Charges and Compliant Billing 189

Chapter 4

Chapter 5

Chapter 6

Part 3 CLAIMS 217

Chapter 7 Healthcare Claim Preparation and Transmission 218

Chapter 8 Private Payers/ACA Plans 259

Chapter 9 Medicare 302

Chapter 10 Medicaid 338

Chapter 11 TRICARE and CHAMPVA 360

Chapter 12 Workers’ Compensation and Disability/Automotive Insurance 377

Part 4 CLAIM FOLLOW-UP AND PAYMENT PROCESSING 401

Chapter 13 Payments (RAs), Appeals, and Secondary Claims 402

Chapter 14 Patient Billing and Collections 434

Chapter 15 Primary Case Studies 458

Chapter 16 RA/Secondary Case Studies 495

Brief Contents

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Chapter 2 Electronic Health Records, HIPAA, and HITECH: Sharing and Protecting Patients’ Health Information 33

 

 

Part 5 HOSPITAL SERVICES 509

Chapter 17 Hospital Billing and Reimbursement 510

Appendix A: Place of Service Codes A-1

Appendix B: Professional Websites B-1

Appendix C: Forms C-1

Abbreviations AB-1

Glossary GL-1

Index IN-1

iv Brief Contents

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