MEDA 136 Coding/Billing/Insurance

• Analyze the different types of managed care plans in local area
• Differentiate between Medicare Part A and Part B
• Review a managed care manual and develop an office policy and procedure for the acceptance of managed care patients
• Obtain pre-certification and pre-authorization for a simulated managed care patient
• Cite advantages and disadvantages of participating and non-participating insurance companies for a physician
• Complete HCFA-1500 forms for a government plan and a commercial carrier
• Outline the procedure for obtaining a managed care referral for a patient
• Outline the procedure for obtaining a pre-certification approval for a patient
• Explain the importance of coding statistics to a utilization study
• Locate codes with modifiers and symbols in the CPT book
• Explain how to locate codes in the HCPCS manual
• Extract procedures from sample charts and match the procedure with the correct code from the CPT book
• Create a master list of the most common diagnostic codes for a specific practice
• Cite which volumes are used primarily by coders in ambulatory care settings
• Extract diagnosis from sample medical charts
• Locate correct diagnostic code in ICD-9 CM coding books
• Complete claim forms using a medical insurance billing software
• Complete claim forms for Blue Cross/Blue Shield, Medicare, Medicaid, commercial carriers, military and managed care
• Reconcile payment rejections with a sample explanation of benefits form
• Cite the process for an appeal of an unpaid claim
• Outline the steps for follow-up on claims
• Review a sample fee schedule for a physician
• Explain the terms, “usual and customary” and “usual and reasonable”
• Define diagnosis-related groups
• Explain the doctor’s fee schedule to the patient
• Understand the correlation of the CPS code(s) to the ICD-9 CM code(s) and the medical necessity for reimbursement of the procedure/service
• Work effectively as a team member in the medical office setting