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Lecture Notes For Comprehensive Medical Coding, 2019 2nd Edition

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    CHAPTER 1: YOUR CODING CAREER INSTRUCTIONAL AND LEARNING OBJECTIVES: After completing this chapter, students should have the skills to: 1.1 Spell and define the key words, medical terms, and abbreviations related to your coding career. (Remember) 1.2 Describe coding, H I P A A - mandated code sets, and coding skills. (Understand) 1.3 Explain how patient encounters relate to coding. (Understand) 1.4 Describe the types of coding certification. (Understand) 1.5 Summarize the career path and performance expectations for a coding career. (Understand) CHAPTER OUTLINE • What is Coding? • Understanding Patient Encounters • Certification • Coding Careers RESOURCES • S tudent textbook , Chapter 1 • Instructor’s Manual with Lesson Plans • Chapter 1 PowerPoint Lecture

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    DETAILED LESSON PLANS Learning Objective 1.1: Spell and define the key words, medical terms, and abbreviations related to your coding career. Concepts for Lecture: 1. The key terms listed at the beginning of each chapter are important concepts for students to know, and appear in blue boldface type throughout the chapter. 2. Students should also become familiar with the terms listed within tables in the chapter. Teaching Notes Teaching Resource: Pearson’s Comprehensive Medical Coding: A Path To Success, Chapter 1 PowerPoint Lecture Slides: In - Class Activities: Read the Professional Profile of Jennifer Holland, R H I T, C P C, C I R C C, who is a coding audit response specialist. • Discuss the following questions as a class or in small groups: o What steps did Jennifer take in her career that enabled her to achieve her goals? o What advice does she offer to medical coding students?

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    Teaching Notes/Tips: 1. Section One: Foundations of Coding consists of two chapters that lay the foundation for this course. It acquaints students with the medical coding field, potential career opportunities, and how coding relates to reimbursement and payment. 2. The Professional Profile on the section opener page is about a coder who worked her way up in coding and is now working as a coding audit response specialist. Many students are interested in the many job opportunities that are available to an experienced m edical coder. Jennifer’s profile introduces students to one of those future careers and describes both the professional challenges and the everyday processes for the coding audit response specialist. Encourage students to identify a realistic plan that wil l enable them to achieve professional goals at the appropriate time in their careers. 3. Refer to Chapter 57 of this text for more information about careers, professionalism, and patient relations. Learning Objective 1.2: Describe coding, H I P A A - mandated code sets, and coding skills. (Understand) Concepts for Lecture: 1. Coding is the process of accurately assigning codes to verbal descriptions of patients’ conditions and the health care services provided to treat those conditions.

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    a. The health care system in the United States uses several distinct systems of medical codes, called code sets, for different purposes. b. The various systems were developed by different organizations and follow different guidelines for their use. 2. Accurate coding requires three major skills: abstracting, assigning, and arranging. a. To abstract, coders read the medical record and determine which elements of the encounter require codes. They identify the reason for the encounter, diagnostic statements from the physician, complications and co - existing conditions, and the services provid ed. b. To assign codes, coders select codes that accurately describe the information documented in the medical record and accurately describe the patient’s condition and services. Locate the Main Term in the Index, then verify the code in the Tabular List. Each c ode must reflect the highest level of specificity possible and contain the correct number of characters for that code. c. To arrange codes, coders must organize or sequence codes in a specific order, based on the official coding guidelines and instructional notes. Codes that are not sequenced properly are not considered to be correct. Teaching Notes Teaching Resource: Pearson’s Comprehensive Medical Coding: A Path To Success , Chapter 1

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    PowerPoint Lecture Slides for Chapter 1 Tables: 1 - 1 H I P A A - Mandated Code Sets Teaching Notes/Tips: 1. Stress that students do not need to memorize individual codes but should memorize the rules and steps of the coding process. 2. Show students copies of the coding manual for each of the H I P A A - mandated code sets. 3. The term abstract also describes a task in health information management in which inpatient coders review the medical record and cull data required for reporting, such as patient demographics and length of stay. Homework Assignment: Coding Practice, Exercise 1.1, What Is Coding?, #1 – 3 Learning Objective 1.3: Explain how patient encounters relate to coding. (Understand) Concepts for Lecture: 1. Coders assign diagnosis and procedure codes to a patient encounter after it has been completed, based on physician documentation. 2. Patient encounters are generally classified by the location of the encounter because different coding and billing rules apply to each category.

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    a. Outpatient encounters are physician interactions with patients who receive services and who have not been formally admitted to a health care institution, such as an acute care hospital, long - term care facility, or rehabilitation facility. b. Inpatient encounters are physician interactions with patients who have been formally admitted to a health care facility, such as an acute care hospital, long - term care facility, or rehabilitation facility. 3. Each encounter generally involves three steps: diagnosis, treatment, and documentation. 4. Establishing or updating a diagnosis involves a history, a physical examination, and testing. a. Refer to the Guided Example throughout this chapter to learn more about patient encounters. b. The Guided Example of a Physician Diagnosis demonstrates how physicians diagnose conditions. 5. The treatment plan may include medication, surgery, lifestyle changes, or therapy. a. Physicians may treat symptoms to provide relief to the patient until they determine the underlying cause. b. The Guided Example of a Treatment Plan demonstrates how physicians determine the treatment plan.

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    6. When physicians document the encounter, they record the reason they saw the patient, the diagnostic techniques used, tests or treatments planned, and their overall assessment of the patient. a. Physicians may treat symptoms to provide relief to the patient until they determine the underlying cause. b. The Guided Example of Documentation demonstrates how the patient encounter is documented. Teaching Notes Teaching Resource: Pearson’s Comprehensive Medical Coding: A Path To Success , Chapter 1 PowerPoint Lecture Slides for Chapter 1 Tables 1 - 2 Examples of Outpatient Encounters Teaching Notes/Tips: 1. This text uses the terms “physician” and “provider” interchangeably to refer to any health care professional who provides services that are billed with I C D - 10 codes. 2. Stress that coders do not code for everything pertaining to a given patient. • Code for the services provided by your employer, such as the hospital, the surgeon, or the physical therapist. • Code for the diagnoses that describe why the patient received these particular services, but do not code for unrelated diagnoses.

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    • Code for services provided during the encounter, but not for previous services or planned services. Homework Assignment: Coding Practice, Exercise 1.2, Understanding Patient Encounters, #1 – 3 Learning Objective 1.4: Describe the types of coding certification. (Understand) Concepts for Lecture: 1. Certification is a voluntary achievement which documents that a coder has attained a certain level of proficiency by passing a rigorous examination. a. Certification is offered by professional organizations and is an additional step beyond a formal educational degree. b. Certification is not mandated by the government and is not a legal requirement. 2. Founded in 1988, A A P C has historically focused on physician - based and outpatient coders. a. Certified Professional Coder ( C P C ® ) certification focuses on coding of services, procedures, and diagnoses for physician offices. b. Certified Professional Coder – Hospital ( C P C - H ® ) certification focuses on outpatient hospital services. c. Certified Professional Coder – Payer ( C P C - P ® ) certification focuses on coding and reimbursement skills needed by payers.

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    d. Certified Professional Coder – Apprentice ( C P C - A ® ) certification is for coders with less than 2 years of experience, or 1 year of experience in addition to formal education. 3. A H I M A has historically focused on hospital coders. a. Certified Coding Specialist (C C S) certification focuses on hospital inpatient and outpatient coding. b. Certified Coding Specialist – Physician ( C C S - P) certification focuses on physician - based coding. c. The Certified Coding Apprentice (C C A) credential is geared toward entry - level coders with little or no job experience. Teaching Notes Teaching Resource: Pearson’s Comprehensive Medical Coding: A Path To Success , Chapter 1 PowerPoint Lecture Slides for Chapter 1 In - Class Activities: 1. Invite an A A P C or A H I M A member to talk to the class about certification and career progression. 2. Refer again to the opening Professional Profile of Jennifer Holland. Discuss the following questions as a class or in small groups: • What certifications did Jennifer earn? • How do you think these certifications helped her reach her goal of moving upward in her medical coding career?

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    Teaching Notes/Tips: 1. Encourage students to join A A P C or A H I M A and participate in local chapter meetings. 2. Students are often intensely interested in the details of certification. Refer to the Web sites of A A P C ( www.aapc.com ) and A H I M A ( www.ahima.org ) for current information on certification requirements for new graduates. Homework Assignment: Coding Practice, Exercise 1.3, Certification, #1 – 3 Learning Objective 1.5: Summarize the career path and performance expectations for a coding career. (Understand) Concepts for Lecture: 1. Students are wise to begin learning about their career path and job performance expectations for accuracy and productivity. 2. A career path is the progression of jobs and responsibilities throughout one’s working life. a. Most coders look for an entry - level job upon graduation in order to gain basic skills, become familiar with the health care field, and establish excellent work habits. b. A mid - level job allows coders to expand their skills, learn new specialties, assume more independence, and take on more responsibility.

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    c. After 5 or so years of proven experience, coders can progress to an advanced - level job, which requires a solid track record of good performance. d. When coders are ready to change jobs and advance their careers, they may seek a new job internally, within their current organization, or they may choose to look externally, for a job with a different company. 3. Performance expectations are the outcomes employers need coders to achieve in order to demonstrate competence in the job. a. Coding jobs have high expectations because securing payment for services from insurance companies requires a high degree of accuracy and productivity by coders. b. The average expectation for coding accuracy areas is 95% to 98%. c. High levels of speed and accuracy in keyboarding are essential, with common minimums of 30 – 40 words per minute (w p m) or 9,000 – 12,000 keystrokes per hour (k s p h). d. Case production standards, the number of cases to be coded each day, are based on the type of record being coded; whether coders are assigning diagnosis codes, procedure codes, or both; whether coders work from paper or electronic charts; and what other responsibilities, such as billing, coders do at the same time. Teaching Notes Teaching Resource: Pearson’s Comprehensive Medical Coding: A Path To Success , Chapter 1

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    PowerPoint Lecture Slides for Chapter 1 Tables: 1 - 3 Examples of Types of Organizations that May Require Coding Skills 1 - 4 Examples of Job Titles that May Require Coding Skills 1 - 5 Examples of a Coding Career Path In - Class Activities: 1. Refer to Table 1 - 3 Examples of Types of Organizations that May Require Coding Skills. 2. Discuss the following question as a class or in small groups: • What are the names of specific organizations in your community that fall into each category identified in this table ? For example, identify the names of nearby hospitals, physician offices, and clinics. • If using small groups, divide the list into sections and assign each group a different section. Combine students’ suggestions into a list to which they can refer and add as they begin job hunting. 3. Refer again to the opening Professional Profile of Jennifer Holland. Discuss the following questions as a class or in small groups: • What was Jennifer’s entry - level job? • What was Jennifer’s mid - level job? • What was Jennifer’s advanced - level job? • How did each job prepare her for the next one?

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    Teaching Notes/Tips: 1. In addition to career information provided by your school’s admissions department and career services department, you also look to coding instructors for more specific information about the coding and billing profession. 2. Help students understand that in coding, like most careers, new graduates do not start at the top; they start at a basic level and work their way up, with greater responsibility and more skills at each level. Consider sharing highlights of your own career path as an example. 3. Take time to review Table 1 - 5 Examples of a Coding Career Path to help students understand the variety of career opportunities available to them. 4. Stress the importance of strong alphanumeric keyboarding skills. Many employers require a keyboarding test before they will conduct interviews with new graduates. If possible, contact your career services department to learn what keyboarding rates are comm on for employers in your area. Homework Assignment: Coding Practice, Exercise 1.4, Coding Careers, #1 – 3 CHAPTER 1 REVIEW Concepts for Lecture: 1. Coding is the process of accurately assigning codes to verbal descriptions of patients’ conditions and the health care services provided to treat those conditions.

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    2. The three skills of an “Ace” coder are abstracting, assigning, and arranging (sequencing). 3. Coders assign diagnosis and procedure codes to patient encounters after the encounter is completed. 4. Certification is a voluntary achievement that documents a coder’s having attained a certain level of proficiency by passing a rigorous examination offered by A A P C or A H I M A . 5. A career path is the progression of jobs and responsibilities throughout one’s career. 6. Performance expectations are the outcomes employers need coders to achieve in order to demonstrate competence in the job. Teaching Notes Teaching Resource: Pearson’s Comprehensive Medical Coding: A Path To Success , Chapter 1 Homework Assignment: Concept Quiz, Completion, #1 – 10 Concept Quiz, Multiple Choice, #1 – 10

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    CHAPTER 2: CODING AND REIMBURSEMENT INSTRUCTIONAL AND LEARNING OBJECTIVES: After completing this chapter, students should have the skills to: 2.1 Spell and define the key words, medical terms, and abbreviations relating to reimbursement. (Remember) 2.2 Describe the types of healthcare payers. (Understand) 2.3 Explain the importance and content of documentation. (Understand) 2.4 Describe the life cycle of an insurance claim. (Understand) 2.5 Summarize the most common reimbursement methods for physicians, i npatient hospitals, and outpatient hospitals. (Understand) 2.6 Recognize the major healthcare claims formats. (Understand) 2.7 Explain the federal compliance initiatives. (Understand) CHAPTER OUTLINE • Healthcare Payers • Documentation • Life Cycle of an Insurance Claim • Reimbursement Methods • Healthcare Claims • Federal Compliance • Health Information Technology RESOURCES • S tudent textbook , Chapter 2

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    • Instructor’s Manual with Lesson Plans • Chapter 2 PowerPoint Lecture • Chapter 2 Image Library DETAILED LESSON PLANS Learning Objective 2.1: Spell and define the key words, medical terms, and abbreviations relating to reimbursement. Concepts for Lecture: 1. The key terms listed at the beginning of the chapter are important concepts for students to know, and appear in blue boldface type throughout the chapter. 2. Students should also become familiar with the terms listed within tables in the chapter. 3. Supplemental terms that appear in black boldface throughout the chapter are defined in the glossary. Teaching Notes Teaching Resource: Pearson’s Comprehensive Medical Coding: A Path To Success, Chapter 2 Page 13

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    PowerPoint Lecture Slides: Teaching Notes/Tips: Point out to students that even if their ultimate jobs do not directly involve billing, they still want to have a basic understanding of how their work as coders impacts reimbursement so they can become valuable team members. Learning Objective 2.2: Describe the types of healthcare payers. Concepts for Lecture: 1. Third - party payers are entities other than the patient or physician that pay for healthcare services. Coders need to understand the various types of third - party payers because each has separate, and sometimes conflicting, rules about coding and billing. 2. Health benefit plans funded by federal or state governments are entitlement programs for which beneficiaries qualify based on specific criteria. a. Medicare is the single largest payer of healthcare services in the United States and pays for healthcare services for most people age 65 and over, people of any age with end - stage renal disease (E S R D), and people with disabilities. Medicare offers four programs, called Part A, hospital insurance; Part B, medical insurance; Part C, managed care; and Part D, prescription drug insurance. b. Medicaid is a program for low - income families that is funded two - thirds by the federal government and one - third by state governments.

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    c. Other government programs include Tricare, State Children’s Health Insurance Program, and the Veteran’s Health Administration. 3. Private health insurance is coverage for healthcare services offered by private corporations, such as Aetna, Cigna, or United Health Care, and not - for - profit organizations, such as Blue Cross and Blue Shield. a. Group health plans are offered by employers and unions, which contract with a private insurance company to provide a specific list of benefits to their employees or members. b. Individual health insurance plans are those that people purchase directly from a health insurance company, such as people who are self - employed or do not have benefits through an employer or government program. c. Workers’ compensation plans pay for medical costs due to employment - related injuries or illnesses, and vary from state to state. d. Automobile insurance policies often include medical payments or personal injury protection, which pays for medical expenses incurred during an automobile accident. e. Managed care plans contract with physicians, hospitals, and other providers to offer services for a lower fee to health plans; then they contract with private health insurance companies and self - insured plans to promote an exclusive network of preferred providers Teaching Notes Teaching Resource: Pearson’s Comprehensive Medical Coding: A Path To Success , Chapter 2

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    Pages 14 – 16 PowerPoint Lecture Slides: In - Class Activities: Discuss the following questions as a class or in small groups. Consider assigning each group a different payer to discuss. • What are the advantages and disadvantages of each type of payer for physicians or hospitals? • What are the advantages and disadvantages of each type of payer for patients? Teaching Notes/Tips: It is important that students understand the relationship between coding and reimbursement. Tailor this part of the lecture to the needs of students. When students have had reimbursement course(s) previously, a quick review may be all that is necessary. Wh en students have had little or no previous coursewo rk, more time will be required. Homework Assignment: Coding Practice, Exercise 2.1, Healthcare Payers, #1 – 3 Learning Objective 2.3: Discuss the importance and content of documentation. Concepts for Lecture: 1. Medical necessity is establishing the medical need for services.

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    a. Payers establish medical necessity rules to avoid paying unscrupulous providers who might provide a service just so they could receive payments, rather than because the patient actually needs the service or would benefit from it. 2. The medical record is the comprehensive collection of all information on a patient at a particular facility. a. The diagnosis and procedure codes reported on the health insurance claim form or billing statement must be supported by information in the medical record for each encounter. b. Documentation is the written or electronic record of medical care and services provided, and may refer to the overall medical record as well as to progress notes. Teaching Notes Teaching Resource: Pearson’s Comprehensive Medical Coding: A Path To Success , Chapter 2 PowerPoint Lecture Slides: Tables: 2 - 1 Examples of Medical Necessity Criteria 2 - 2 Elements of a Progress Note and Their Use in Coding 2 - 3 Elements of a Medical Record and Their Use in Coding Figures: 2 - 1 Example of a paper - based medical record.

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    2 - 2 Example of an electronic health record. In - Class Activities: Review the examples in Table 2 - 1. Discuss the following question as a class, in small groups, or on an online discussion board: • What are other examples of appropriate and inappropriate medical services? Teaching Notes/Tips: Stress that coders should not manipulate codes in a way that distorts or alters the diagnoses and procedures as documented in the medical record. Coders need to be certain they are accurately describing everything that was done for the patient and the reas ons for which the services were provided. Homework Assignment: Coding Practice, Exercise 2.2, Documentation, #1 – 3 Learning Objective 2.4: Describe the life cycle of an insurance claim. Concepts for Lecture: 1. Each step involved in converting a patient encounter into a paid insurance claim needs to be completed in a timely and accurate manner in order for providers to receive correct payment for their services 2. Although providers do not code or bill for scheduling an appointment, the appointment begins when providers begin collecting insurance information.

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    3. After completing registration information, a patient sees the physician and/or receives the treatments and procedures needed. The physician documents the patient’s problem in a progress note and may check off services and diagnoses on an encounter form or charge slip. 4. The encounter is coded based on a charge slip or information directly from the medical record; then the bill is prepared and submitted to the insurance company. 5. When payers receive electronic claims, the computer system first performs a front - end edit check, which scans the claims for valid data including the policy number, patient name, provider number, diagnosis codes, and procedure codes. a. A rejected claim is one that is not accepted into the insurance company’s computer system for processing due to missing or invalid data. b. Clean claims are those which pass the front - end edit checks and have no missing or invalid information. Most clean claims are processed using automatic adjudication , a process in which the computer automatically determines benefits and payment. c. Some claims are suspended from the automatic process for manual review in order to gather more information before payment is determined. d. After the payer has processed the claim, the provider receives a check or electronic deposit and an E O B. e. If payment was denied for one service or for the entire claim, an accounts receivable specialist needs to investigate the reason.

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    f. After all insurance payments are received and follow - up is complete, the office sends the patient a bill for any deductible, coinsurance, or patient responsibility amounts that have not been paid. Teaching Notes Teaching Resource: Pearson’s Comprehensive Medical Coding: A Path To Success , Chapter 2 PowerPoint Lecture Slides : Tables : 2 - 1 C oding Problems Causing Rejected or Denied Claims In - Class Activities : As a class, or in small groups, create a flow chart that illustrates each step in the life cycle of an insurance claim. Active participation and visualization help students understand a complex process. Teaching Notes/Tips: 1. Point out to students that the billing and coding procedures are not exactly the same in every office and every hospital, but the general process is similar. 2. A student intern or new coder can bring immense value to an organization by offering to follow up on problem and unpaid claims. Positive financial results are almost always seen on claims that are reactivated. In addition, new coders can learn a tremendous amount about coding and the payment process by doing insurance follow - up.

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    Homework Assignment : Coding Practice, Exercise 2.3, Life Cycle of an Insurance Claim, #1 – 3 Learning Objective 2.5: Summarize the most common reimbursement methods for physicians, inpatient hospitals, and outpatient hospitals. Concepts for Lecture: 1. The healthcare industry uses many different reimbursement or payment methods for services. The methods vary by type of payer; the setting, such as physician’s office, outpatient hospital, or inpatient hospital; and the type of service. It is important to u nderstand the terminology associated with reimbursement. a. Fee schedule is a list of services with charges. b. Negotiated rate schedule or a discounted fee schedule specify lower, reduced rates, or rates agreed upon by the payer and the type of setting. c. Prospective payment system (P P S) is a reimbursement method in which payment is made based on a predetermined fixed amount per case. d. Medicare uses the inpatient prospective payment system (I P P S). e. Medicare also uses the outpatient prospective payment system (O P P S). f. Capitation is a prospective payment system in which physicians are paid a fixed amount per month for each member assigned to them, regardless of whether that person requests services. 2. Physician Reimbursement

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    a. Physicians are reimbursed based on fee schedules and capitation. Medicare publishes the Medicare Physician Fee Schedule (M P F S), updated annually. b. Medicare uses a resource - based relative value scale (R B R V S) to establish reimbursement rates. c. A relative value unit (R V U) identifies the amount of work and expense involved in providing a particular service. d. Geographic costs are also factored into the calculation of R B R V S . This is called a geographic practice cost index (G P C I). e. Annual conversion factor (C F) is used to calculate the fees. 3. Inpatient Hospital Reimbursement a. Inpatient hospitals are reimbursed based on fee schedules; per diem payment (an all - inclusive flat charge per day); and prospective payment. b. Diagnosis - related groups (D R G s) are the most common prospective payment system. Hierarchical condition category (H C C) coding further fine - tunes reimbursement. c. Best - known D R G s are the Medicare severity - adjusted D R G s (M S - D R G s ). d. Case - based payment means that the rate is determined per case, or per inpatient admission. e. Cost outliers are unusual cases in which the cost is above or below a standard threshold amount established for the D R G. f. A D R G grouper is software that considers several clinical and demographic characteristics of a patient.

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    g. Hierarchical condition category coding ( H C C ) was developed to estimate future health risks and costs for Medicare Advantage and inpatients. The focus is to identify inpatients with chronic, high - cost illnesses, s uch as certain types of cancer. 4. Outpatient Hospital Reimbursement a. C M S O P P S assigns individual services to an ambulatory payment classification (A P C) based on similar clinical cha racteristics and similar costs. b. Private payers may adopt Medicare A P C s, modify them, establish their own, or pay based on individual C P T codes. 5. Reimbursement in other settings includes inpatient rehabilitation hospitals, ambulatory surgery centers, skilled nursing facilities, home health agencies, and others. Teaching Notes Teaching Resource : Pearson’s Comprehensive Medical Coding: A Path To Success , Chapter 2 PowerPoint Lecture Slides In - Class Activities : Discuss the extensive terminology and the acronyms as sociated with that terminology. Discuss the role Medicare and C M S play in establishing fees and reimbursement.

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    Discuss how important reimbursement is in all medical settings. Teaching Notes/Tips : 1. Show how a fee is established by multiplying the total R B R V S value for a C P T code by the annual conversion factor ( C F ). For example, a conversion factor of $35 means that an R B R V S value of 1.0 is worth $35 on the M P F S . A code with an R B R V S value of 0.5 would be worth $17.50. A code with an R B R V S value of 2.0 would be worth $70. A code with an R B R V S value of 10.0 would be worth $3,500. When Medicare adjusts prices each year, it publishes a new conversion factor that is applied to all C P T codes. 2. When discussing D R G groupers, be sure to mention the seen variables, including principal diagnosis, secondary diagnosis, surgical procedures, complications and comorbidities, age and gender, discharge status, and trim points. Show the students an example. ( An example of a M S - D R G is D R G 375 Digestive Malignancy with Complication or Comorbidity. The M D C for this D R G is M D C 06 Diseases and Disorders of the Digestive System.) Homework Assignment Coding Practice Exercise 2.4, Reimbursement Methods, # 1 - 3 Learning Objective 2.6: Recognize the major healthcare claims formats.

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    Concepts for Lecture: 1. Providers must submit claims for services to payers to receive reimbursement. Specific formats or forms are required in each healthcare setting. 2. After completing registration information, a patient sees the physician and/or receives the treatments and procedures needed. The physician documents the patient’s problem in a progress note and may check off services and diagnoses on an encounter. 3. Physicians bill services on the C M S - 1500 form. The electronic format for claims submission of physician services is the 837P. a. The National Uniform Claim Committee (N U C C) provides specific guidelines for completion. b. Items 1 – 13 are for patient and insured information. c. Items 14 – 33 are for physician or supplier information. 4. Inpatient hospitals bill services on the U B - 04, also known as the C M S - 1450. The electronic format is the 837I. The National Uniform Billing Committee (N U B C) maintains and updates this form. a. There are 81 form locators or boxes that must be completed. There are very specific rules that apply to each locator. b. Instructions to complete the form are found on either www.cms.gov or www.nubc.org . 5. The U B - 04/837I is used to bill the facility portion of outpatient services and the C M S - 1500 is used to bill for professional services.

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    Teaching Notes Teaching Resource : Pearson’s Comprehensive Medical Coding: A Path To Success , Chapter 2 PowerPoint Lecture Slides Figures: Figure 2 - 3 Example of a completed C M S - 1500 claim form. Figure 2 - 4 Example of a completed U B - 04 form (with annotations). In - Class Activities: Have the students complete a C M S - 1500 form based on a patient’s encounter form. As a group, have the students complete a U B - 04 based on a patient’s hospital stay. Teaching Notes/Tips : 1. Electronic standards specify exactly how data is to be submitted, so that payers’ computers can read the information submitted by providers and clearinghouses. 2. Discuss the “crosswalk” between the paper form and the electronic format. 3. Go to the website www.nucc.org . 4. Go to www.nubc.org . 5. Carefully review the codes and information that populate the locators on the form U B - 04.

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    Homework Assignment: Coding Practice Exercise 2.5, Healthcare Claims, #1 - 5 Learning Objective 2.7: Explain the federal compliance initiatives. Concepts for Lecture: 1. In this era of electronic transmissions, it is much easier for payers to track patterns of billing, compare a physician’s fees with the average or norm, and target providers who deviate from the norm. a. If the insurance company or Medicare detects a pattern of overpayments due to over coding or improper billing, it can conduct an audit . b. Fraud is knowingly billing for services that were never given or billing for a service that has a higher reimbursement than the service actually provided. c. Abuse is mistakenly accepting payment for items or services that should not be paid for by Medicare, due to improper coding and billing practices. d. Compliance means following the rules established by multiple federal, state, and county government agencies. 2. The Office of the Inspector General is a division of D H H S which investigates fraud, abuse, and other noncompliance matters in the Medicare and Medicaid programs. a. The federal False Claims Act imposes penalties on individuals and companies that defraud government programs.

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