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MEDICAL BILLING AND CODING CERTIFICATION DOWNLOADABLE EBOOK 2 | TABLE OF CONTENTS TABLE OF CONTENTS Introduction 5 SECTION 1 What is Medical Billing and Coding? 6 Working in Medical Billing and Coding 8 Medical Coding Certification 12 Medical Billing Certification 14 SECTION 2 Learn More About Medical Coding 16 Medical Coding Vocabulary & Key Terms 22 ICD-9 & ICD-9-CM 26 Using ICD-9-CM 34 ICD-10-CM 38 Using ICD-10-CM 44 Intro to CPT 48 Using CPT 54 CPT Modifiers 60 Human Anatomy and Medical Terminology 68 HCPCS Codes 78 HCPCS Modifiers 82 Crosswalking 86 Electronic vs. Paper Coding 90 Medical Coding Review 92 SECTION 3 Introduction to Medical Billing 98 Medical Billing Vocabulary 102 The Medical Billing Process 108 More About Insurance and the Insurance Claims Process 112 Medicare & Medicaid 116 Medicare, Medicaid and Medical Billing 120 Potential Billing Problems and Returned Claims 122 HIPAA 101 126 HIPAA and Medical Billing 130 Medical Billing Review 132 SECTION 4 Try Medical Coding 136 Try Medical Billing 142 Common Problems in Medical Coding 146 TABLE OF CONTENTS | 3 TABLE OF CONTENTS SECTION 5 What is the CPC Exam? 148 General Preparation and Test Strategies for the CPC Exam 152 CPC Exam: Anesthesia 156 CPC Exam: Radiology 160 CPC Exam: Medicine 162 CPC Exam: The Nervous System 166 CPC Exam: the Endocrine System 168 CPC Exam: Digestive System 172 CPC Exam: The Urinary System 174 CPC Exam: The Musculoskeletal System 176 CPC Exam: Evaluation and Management 178 CPC Exam: Anatomy and Physiology 182 CPC Exam: Mediastinum and Diaphragm 186 CPC Exam: Practice Management 188 CPC Exam: Male and Female Genital System 190 CPC Exam: Hemic and Lymphatic System 192 CPC Exam: Maternity and Delivery 194 CPC Exam: Eye and Ocular Adnexa 196 CPC Exam: ICD-9-CM 198 CPC Exam: HCPCS Level II 200 CPC Exam: Coding Guidelines 202 CPC Exam: Medical Terminology 204 CPC Exam: Pathology and Laboratory 208 CPC Exam: Integumentary 210 CPC Exam: Respiratory System 212 CPC Exam: Cardiovascular System 214 CPC Exam: Where to Take an Exam 216 The CPC Apprentice Program 218 The CPB Exam 220 SECTION 6 Accredited Billing and Coding Schools 222 How to Recognize Industry Scams 226 Getting Your First Medical Billing and Coding Job 228 4 | INTRODUCTION INTRODUCTION | 5 INTRODUCTION This ebook will brief you on every aspect of the medical billing and coding field: from a breakdown of each code set to starting your own practice. DOWNLOADABLE MATERIAL Along with our online video courses, we provide free downloadable resources like Powerpoint presentations, vocabulary lists, sample problems, and review quizzes to help you in your studies. The course is divided into six sections. In section one, we introduce you to the general topic of medical billing and coding. In section two, we talk about the practice and the basics of the medical coding process. In section three, you learn about the medical billing claims process and how it pertains to health insurance payers, Medicare and Medicaid, and the rest of the healthcare industry. In section four, we apply the knowledge you’ve learned and work with some real-world problems in coding and billing. This section gives you a detailed look into what it’s like to work as a medical coder or biller. In section five, we help you prepare for the American Association of Profession- al Coder’s Certified Professional Coder exam. And finally, in section six we show you some of the next steps to take in the field, including where to go to school, where to get certified, and how to avoid online scams. DISCLAIMER Bear in mind that this ebook, and all our provided content on our website alone will not prepare you to take the exams to become a certified medical biller or coder. In order to learn the specifics of these fields and prepare yourself for their exams, you’ll want to take classes at one of the many schools and training programs around the country. You can count on us for that, too: our website can help you pick out the school or training program that’s right for you. Let’s get started! 6 | SECTION 1 WHAT IS MEDICAL BILLING AND CODING? Medical billing and coding are two closely related aspects of the modern health care industry. Both practices are involved in the immensely important reimbursement cycle, which ensures that health care providers are paid for the services they perform. MEDICAL CODING Medical coding, at it’s most basic, is a little like translation. It’s the coder’s job to take something that’s written one way (a doctor’s diagnosis, for example, or a prescription for a certain medication) and translate it as accurately as possible into a numeric or alphanumeric code. For every injury, diagnosis, and medical procedure, there is a corresponding code. There are thousands and thousands of codes for medical procedures, out- patient procedures, and diagnoses. We’ll cover which codes represent which injury or sickness, and which codes correspond to each procedure, in greater depth in Section 2. For now, let’s start with a quick example of medical coding in action. MEDICAL CODING EXAMPLE A patient walks into a doctor’s office with a hacking cough, high production of mucus or sputum, and a fever. A nurse asks the patient their symptoms and performs some initial tests, and then the doctor examines the patient and diagnoses bronchitis. The doctor then prescribes medication to the patient. Every part of this visit it recorded by the doctor or someone in the healthcare provider’s office. It’s the medical coder’s job to translate every bit of relevant information in that patient’s visit into numeric and alphanumeric codes, which can then be used in the billing process. There are a number of sets and subsets of code that a medical coder must be familiar with, but for this example we’ll focus on two: the International Classification of Diseases, or ICD, codes, which correspond to a patient’s injury or sickness, and Current Procedure Terminology, or CPT, codes, which relate to what functions and services the healthcare provider performed on or for the patient. These codes act as the universal language between doctors, hospi- tals, insurance companies, insurance clearinghouses, government agencies, and other health-specific organizations. The coder reads the healthcare provider’s report of the patient’s visit and then translates each bit of information into a code. There’s a specific code for what kind of visit this is, the symptoms that patient is showing, what tests the doctor does, and what the doctor diagnoses the patient with. Every code set has its own set of guidelines and rules. Certain codes, like ones that signify a pre-existing condition, need to be placed in a very particular order. Coding accurately and within the specific guidelines for each code will affect the status of a claim. WHAT IS MEDICAL BILLING AND CODING? | 7 The codes for the procedures performed must also correspond to the diagnoses made by the physician. Having the correct procedure codes match up with the diagnosis codes ensures that healthcare providers and patients will be properly reimbursed by insurance companies. The coding process ends when the medical coder enters the appropriate codes into a form or software program. Once the report is coded, it’s passed on to the medical biller. MEDICAL BILLING On one level, medical billing is as simple as it sounds: medical billers take the information from the medical coder and make a bill for the insurance compa- ny. This bill is called a claim, and will be discussed more in depth in Section 3. The biller also receives evaluated or ‘adjudicated’ claims, analyzes them, and then creates bills for patients. Of course, as with everything related to the health care system, this process isn’t as simple as it seems. MEDICAL BILLING EXAMPLE To get a better look at medical billing, let’s rewind the example we used earlier. Our same patient has a cough, a fever, and is producing lots of mucus. This pa- tient calls the doctor and schedules an appointment. It’s here that the medical billing process begins. The medical biller takes the codes, which show what kind of visit this is, what symptoms the patient shows, what the doctor’s diagnosis is, and what the doctor prescribes, and creates a claim out of these using a form or a type of software. The biller then sends this claim to the insurance company, which evaluates and returns it. The biller then evaluates this returned claim and fig- ures out how much of the bill the patient owes, after the insurance is taken out. If our bronchitis-afflicted patient has an insurance plan that covers this type of visit and the treatment for this condition, their bill will be relatively low. The patient may have a co-pay, or have some other form of arrangement with their insurance company. The biller takes all of this into account and creates an accurate bill, which is then passed on to the patient. In the case of a patient being delinquent or unwilling to pay the bill, the med- ical biller may have to hire a collections agency in order to ensure that the healthcare provider is properly compensated. The medical biller, acts as a sort of waypoint between patients, healthcare providers, and insurance companies. Think of the biller, like the coder, as a sort of translator—where the coder translates medical procedures into code, the biller translates codes into a financial report. The biller has a number of other responsibilities, which we’ll discuss further in Section 3, but for now you should simply know that the biller is in charge of making sure the healthcare provider is properly reimbursed for their services.

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