Medical Insurance is designed around the medical billing cycle with each part of the book dedicated to a section of the cycle followed by case studies to apply the skills discussed in each section. The medical billing cycle now follows the overall medical billing and documentation cycle used in practice management/electronic health records environments and applications.

Because of the mandate to the health care industry to adopt ICD-10-CM/PCS on October 1, 2014, students must work to gain expertise using this coding system. For this reason, ICD-10 is the primary diagnostic coding system taught and exemplified in the sixth edition of Medical Insurance. An alternate to Chapter 4 on ICD-9-CM (Chapter 18) is provided online for additional study if the instructor elects to cover it in more depth.

Medical Insurance offers several options for completing the case studies at the end of Chapters 8–12 and throughout Chapter 15:

• Paper Claim Form If you are gaining experience by completing a paper CMS-1500 claim form, use the blank form supplied to you (from the back of Medical Insurance or printed from a PDF file on the book’s Online Learning Center, www.mhhe.com/valerius6e), and follow the instructions in the text chapter that is appropriate for the particular payer to fill in the form by hand.
• Electronic CMS-1500 Form If you are assigned to use the Interactive simulated CMS-1500 form, access either the HTML or Adobe Form Filler form at the book’s Online Learning Center, www.mhhe.com/valerius6e. See Appendix B, The Interactive Simulated CMS-1500 Form, for further instructions.
• Connect Plus Connect Plus provides simulated Medisoft ® exercises in four modes: Demo, Practice, Test, and Assessment. The exercises simulate the use of Medisoft Advanced Version 17 to complete the claims. If you are assigned this option, you should read Appendix A, Guide to Medisoft, as the first step, and then follow the instructions that are printed in each chapter’s case studies. In this version, some data may be prepopulated to allow the students to focus on the key tasks of each exercise. These simulations are autograded.

• Pedagogy
• Learning Outcomes are restated to reflect the range of difficulty levels to teach and assess critical thinking about medical insurance and coding concepts and continue to reflect the revised version of Bloom’s Taxonomy.
• HIPPA-Related Updates
• 2013 ICD-10-CM and CPT/HCPCS codes are included.
• The new Notice of Privacy Practices (NPP) that addresses disclosures in compliance with HITECH is illustrated.
• Chapter-by-Chapter
• Chapter 1: New key terms: electronic health records (EHR), health information technology (HIT), revenue cycle management, and medical billing cycle, PM/EHR, cash flow, and accounts payable (AP). New Learning Outcome 1.1 emphasizes revenue cycle management and the role played by the medical insurance specialist in this process. The medical billing cycle introduced here has been revised to conform to the EHR-based workflow presented in the medical documentation and billing cycle used in the PM/EHR.
• Chapter 2: New key terms: accountable care organization (ACO), accounting of disclosure, Heath Information Exchange (HIE), meaningful use incentives, medical documentation and billing cycle, Office of E-Health Standards and Services (OESS), and operating rules. New Learning Outcomes 2.1 and 2.2 emphasize EHRs and their meaningful use as part of the discussion of documentation. Increased illustrations that show completed EHR screens rather than paper documents are included. A new OCR breach case and a new OCR physician practice case are provided. The new Notice of Privacy Practices (NPP) that addresses disclosures in compliance with HITECH is presented.
• Chapter 3: New to this chapter are an updated flow chart on EP vs. NP based on CPT 2012; a new patient information form to collect race, ethnicity, and language for meaningful use incentives and compliance with 5010; explanation of how to determine primary coverage when the patient has a group and an individual plan; and ICD-10-CM codes placed on the encounter form illustration. Former learning outcome 3.10 to has been moved to Chapter 6 as Learning Outcome 6.11 to follow revised medical billing cycle.
• Chapter 4: This chapter has been completely rewritten to provide instruction on correct coding with ICD-10-CM and includes a brief comparison with ICD-9-CM and notes on how to research ICD-9 codes when required.
• Chapter 5: CPT and HCPCS have been combined into one chapter for consistency and appropriate level of coverage for these code sets (represents Chapters 5 and 6 from the previous edition, and as such, all subsequent chapters have been renumbered). The chapter also defines new modifier 33, provides a new definition of moderate sedation (no longer conscious) for E/M code range 99143–99150, and standardizes the use of the term descriptor.
• Chapter 6: New key terms: adjustment, bundled payment, and walkout receipt. This chapter proves an explanation of the major global period indicators and a new exercise on accessing the period data by CPT code. The check of outpatient procedures from Chapter 3 has been added to follow the medical billing cycle more precisely. A new Billing Tip explains that some practices use the term contractual adjustment rather than write-off. A Health Reform feature box explains the concept of bundled payments: a single payment for an entire episode of care to all providers
• Chapter 7: The CMS-1500 claim completion information for the current Reference Instruction Manual at NUCC.org has been updated. NUCC guidance on reconciling the CMS-1500 with the 5010 format for the 837P is included. According to the NUCC, some item numbers report data that are not reported on the 837P, and the organization recommends not reporting them on the CMS-1500. Following these guidelines requires a number of modifications to instructions, including not reporting the patient’s telephone number, patient status, other insured’s DOB and employer/school, insured’s employer or school name, same/similar illness, balance due, and signature indication. The reference has been changed from 837 to 837P for clarity; the 837I is defined in Chapter 17. Appendix C, Medical Specialties and Taxonomy Codes that was referenced here has been deleted; the website is more current and should be used. The discussion includes completing the 837P updated for 5010 claim completion requirements, such as no P.O. box or lock box addresses for the billing provider and new information needed for unlisted CPT/HCPCS codes and presents new 5010 definitions for billing provider, pay-to provider, rendering provider, and referring provider.
• Chapter 8: New key term: FAIR Health. Claim completion instructions have been updated to comply with NUCC CMS-1500 guidelines and ICD-10-CM codes.
• Chapter 9: New key terms: annual wellness visit (AWV), cost sharing, Internet-Only Manuals (IOM), Medicare Learning Matters (MLN), and United States Preventive Services Task Force (USPSTF). The term Physician Quality Reporting System (PQRS) has been updated as have the recovery auditor program and Zone Program Integrity Contractor (ZPIC). There is a new form and new learning objective on completing the new ABN; 2012 Part A and Part B premium/deductibles/coinsurance; the section on ACA/USPSTF updates for preventive services coverage have been expanded; new material pulls together the various incentive programs; physician enrollment website information (PECOS) is included, and claim completion instructions have been updated to comply with NUCC CMS-1500 guidelines and ICD-10-CM codes.
• Chapter 10: The material includes coverage of the ACA effect on Medicaid enrollment in 2014 and updates of CHIP terminology and statistics, Medicaid managed care enrollment percentage, and claim completion instructions to comply with NUCC CMS-1500 guidelines and ICD-10-CM codes.
• Chapter 11: Cost sharing for Figure 11.2 and claim completion instructions to comply with NUCC CMS-1500 guidelines and ICD-10-CM codes have been updated.
• Chapter 12: New key terms: automotive insurance policy, personal injury protection, liens, and subrogation. The topic of automotive insurance has been added. ICD-10-CM codes are used.
• Chapter 13: The material uses ICD-10-CM codes and redefines RA/EOB into two parts: the RA for the provider and the EOB for the beneficiary per current industry practice.
• Chapter 14: New key terms: nonsufficient funds (NSF) check, collection ratio. The chapter includes the se of ICD-10-CM. Instructions on processing an NSF and an example of calculating the elements for a payment plan (items from a Truth in Lending form) are presented.
• Chapters 15 and 16: Case studies for ICD-10-CM and for NUCC CMS-1500 guidelines have been updated.
• Chapter 17: New key terms: inpatient-only list, three-day payment window, and ICD-10-PCS. There is a new section on coding with ICD-10-PCS and the use of ICD-10-CM. For a detailed transition guide between the fifth and sixth editions, visit www.mhhe.com/valerius6e.