MAP 172 - Medical Office Management II-A

• Gain understanding of Health Insurance and the relationships between Patients, Providers and Insurance Companies/Third-Party Payers.
• Understand how to translate the medical exam/medical record into procedural and diagnostic codes.
• Understand the process involved in billing services for patients to insurance companies and obtaining reimbursement.

Course Objectives:

Unit 1: Health Insurance Essentials

• Discuss the purpose of health insurance and discuss the concept of cost sharing.
• List and discuss various government-sponsored plans.
• Summarize private health insurance plans.
• Review traditional (fee-for-service) health insurance plans.
• Differentiate among the different types of managed care models.
• Identify managed care requirements for patient referral
• Identify types of third-party plans
• Identify processes for: a. verification of eligibility for services; b. precertification/preauthorization; c. tracking unpaid claims; d. claim denials and appeals
• Discuss participating provider contracts, including contracted fee schedules.
• Interpret information on an insurance card
• Verify eligibility for services
• Describe other types of insurance, including disability, life, long-term care and liability insurance.
• Obtain precertification or preauthorization including documentation
• Define the following: a) bundling and unbundling of codes; b) advanced beneficiary notice (ABN); c) allowed amount; d) deductible; e) co-insurance; f) co-insurance

Unit 2: Diagnostic Coding Essentials

• Describe the historical use of the International Classification of Disease (ICD) in the United States and describe how diagnostic coding is related to medical necessity.
• Identify the structure and format of the ICD-10-CM.
• Describe how to use the Alphabetic Index to select main terms, essential modifiers, and the appropriate code (or codes) and code ranges.
• Explain how to use the Tabular List to select main terms, essential modifiers, and the appropriate code (or codes) and code ranges.
• Summarize coding conventions as defined in the ICD-10-CM coding manual.
• Review the official coding guidelines to assign the most accurate ICD-10-CM diagnostic code.
• Explain how to abstract the diagnostic statement from a patient’s health record.
• Identify the current procedural and diagnostic coding systems, including Healthcare Common Procedure Coding Systems II (HCPCS Level II).
• Perform diagnostic coding.
• Identify how encoder software can help the coder assign the most accurate diagnostic codes.
• Explain the importance of coding guidelines for accuracy, discuss special rules and considerations that apply to the code selection process, and maximize third-party reimbursement.
• Review medical coding and ethical standards.

Unit 3: Procedural Coding Essentials

• List and describe the three code categories in the CPT manual.
• Distinguish between the Alphabetic Index and the Tabular List in the CPT code set.  Also list the six different sections of the tabular list.
• Discuss special reports, and explain the importance of modifiers in assigning CPT codes.
• Review various conventions in the CPT code set.
• Identify the required medical documentation for accurate procedural coding.
• Describe the steps that should be taken in order to be efficient with CPT procedural coding. Also discuss how to use the Alphabetic Index and the Tabular List.
• Identify CPT coding guidelines for Evaluation & Management (E/M) procedures.
• Perform procedural coding
• Identify CPT coding guidelines for anesthesia procedures.
• Identify CPT coding guidelines for surgery procedures.
• Discuss coding factors for the integumentary system and muscular system, and for maternity care and delivery.
• Identify CPT coding procedure for Radiology, Pathology, Laboratory and Medicine sections.
• Identify the current procedural and diagnostic coding systems, including Healthcare Common Procedure Coding Systems II (HCPCS Level II).
• Identify the effects of a.) upcoding, b.) downcoding
• Identify procedures and services that require HCPCS codes.
• Summarize common HCPCS coding guidelines.
• Utilize tactful communication skills with medical providers to ensure accurate code selection.