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INSURANCE AND CODING Chapter 6 © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED
LEARNING OUTCOMES: WHEN YOU FINISH THIS CHAPTER YOU WILL BE ABLE TO 6.1Define medical insurance and coding terminology 6.2Explain the differences among the types of insurance plans 6.3Compare and contrast PAR and nonPAR and the methods insurance companies use to determine how much a provider is paid 6.4Explain diagnostic coding, procedural coding, and coding compliance 6.5Identify structural changes in coding with the implementation of ICD-10 and explain the advantages of the changes © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 6-2
accepting assignment carrier allowed chargeCenters for Medicare and Medicaid Services (CMS) assignment of benefits CHAMPVA balance billingcode linkage birthday rulecoinsurance Blue Cross and Blue Shield (BCBS) coordination of benefits (COB) capitationcopayment (copay) CPTfee-for-service customary feeHCPCS deductibleHMO (health maintenance organization) Defense Enrollment Eligibility Reporting System (DEERS) diagnosis-related groups (DRGs) © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED KEY TERMS 6-3
KEY TERMS (CONTINUED) accepting assignment -- A PAR provider who agrees to accept the allowed charge set forth by the insurance company as payment in full for a service and not bill the patient for the balance allowed charge -- is the most the insurance company will pay any provider for that work and may not be the same as the charged amount assignment of benefits -- agrees to receive payment directly from the patient’s insurance carrier © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 6-4
KEY TERMS (CONTINUED) balance billing -- If the physician decides the patient should absorb the cost, the physician bills the patient for the unclaimed amount birthday rule -- is used as a guideline for determining which of two parents with medical coverage has the primary insurance for a child Blue Cross and Blue Shield (BCBS) -- one of the largest private sector payers in the United States, has both for-profit and nonprofit components capitation -- is the prepayment by the insurance carrier of a fixed (per capita, or per head) amount to a physician to cover the healthcare services for each member of one of its plans for a specified period of time, such as for a month © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 6-5
KEY TERMS (CONTINUED) carrier – Insurance companies that provide the service Centers for Medicare and Medicaid Services (CMS) -- is responsible for setting up the terms of the plan CHAMPVA -- which stands for Civilian Health and Medical Program of the Veterans Administration, is a government health insurance program that covers the expenses of the families of veterans with total, permanent, service-connected disabilities. It also covers surviving spouses and dependent children of veterans who died in the line of duty © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 6-6
KEY TERMS (CONTINUED) code linkage -- On correct claims, each reported service is connected to a diagnosis that supports the procedure as necessary to investigate or treat the patient’s condition. Insurance company representatives analyze this connection between the diagnostic and the procedural information coinsurance -- is the percentage of each covered claim that the insured must pay, according to the terms of the insurance policy coordination of benefits (COB) -- in an insurance policy provides that a patient who has two or more insurance policies can have only a maximum benefit of 100 percent of the health costs copayment (copay) -- Every time HMO members visit their physician, they pay a set charge © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 6-7
KEY TERMS (CONTINUED) CPT -- most commonly used system of procedure codes is found in the Current Procedural Terminology customary fee -- determined by what physicians with similar training and experience in a certain geographic location typically charge for a procedure deductible -- is a certain amount of allowable or covered medical expense the insured must incur before the insurance carrier will begin paying benefits Defense Enrollment Eligibility Reporting System (DEERS) -- used to verify eligibility diagnosis-related groups (DRGs) – Diagnostic groupings are based on the resources that physicians and hospitals have used nationally for patients with similar conditions, taking into account factors such as age, gender, and medical complications © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 6-8
TERMS (CONTINUED) fee-for-service -- is made by the insurance carrier after the patient has received medical services HCPCS -- The Health Care Financing Administration’s Common Procedure Coding System HMO (health maintenance organization) -- is a medical center or a designated group of physicians that provides medical services to insured persons for a monthly or an annual premium © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 6-9
6.1. DEFINE MEDICAL INSURANCE AND CODING TERMINOLOGY The Medical Insurance Contract Insured Premium Third-Party Payer Coordination of Benefits The Birthday Rule © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 6-10
There are many medical insurance plans from which people can choose and many different insurance companies that offer them. Indemnity Plans Managed Care Plans © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED EXPLAIN THE DIFFERENCES AMONG THE TYPES OF INSURANCE PLANS.
6.3. COMPARE AND CONTRAST PAR AND NONPAR AND THE METHODS INSURANCE COMPANIES USE TO DETERMINE HOW MUCH A PROVIDER IS PAID. PAR NONPAR © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 6-12
6.4. EXPLAIN THE DIAGNOSTIC CODING, PROCEDURAL CODING, AND CODING COMPLIANCE Coding compliance is the process of coding using actions that satisfy federal official requirements and guidelines. Individual carrier guidelines must also be followed in order to be considered compliant. The ICD-9-CM CPT-4 HCPCS © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 6-13
6.5. IDENTIFY STRUCTURAL CHANGES IN CODING WITH THE IMPLEMENTATION OF ICD-10 AND EXPLAIN THE ADVANTAGES OF THE CHANGES. ICD-10 is scheduled for mandated implementation October 1, 2013 ICD-10 will contain substantially more codes from which to choose and the codes will be alphanumeric, containing a letter followed by up to five digits. Clinical details will be noted using a sixth digit. © 2012 THE MCGRAW-HILL COMPANIES, INC. ALL RIGHTS RESERVED 6-14
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