Lecture Notes For Comprehensive Medical Coding, 2019 2nd Edition

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CHAPTER 1: YOUR CODING CAREERINSTRUCTIONAL AND LEARNING OBJECTIVES:After completing this chapter,studentsshould have the skills to:1.1Spell and define the key words, medical terms, and abbreviations relatedtoyour coding career. (Remember)1.2Describe coding, HIPAA-mandated code sets, and coding skills.(Understand)1.3Explain how patient encounters relate to coding. (Understand)1.4Describe the types of coding certification. (Understand)1.5Summarize the career path and performance expectations for a codingcareer.(Understand)CHAPTER OUTLINE•What is Coding?•Understanding Patient Encounters•Certification•Coding CareersRESOURCES•Student textbook, Chapter 1•Instructor’s Manual with Lesson Plans•Chapter1PowerPoint Lecture

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DETAILED LESSON PLANSLearning Objective 1.1:Spell and define the key words, medical terms, and abbreviations related to yourcoding career.Concepts for Lecture:1.The key terms listed at the beginning of each chapter are important conceptsfor students to know, andappear in blue boldface type throughout thechapter.2.Students should also become familiar with the terms listed within tables in thechapter.Teaching NotesTeaching Resource:Pearson’s Comprehensive Medical Coding:A Path To Success, Chapter 1PowerPoint Lecture Slides:In-Class Activities:Read the Professional Profile of Jennifer Holland, RHIT, CPC, CIRCC, who is acoding audit response specialist.•Discuss the following questions as a class or in small groups:oWhat steps did Jennifer take in her career that enabled her to achieveher goals?oWhat 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 thefoundation for this course. It acquaints students with the medical codingfield, potential career opportunities, and how coding relates toreimbursement and payment.2.The Professional Profile on the section opener page is about a coder whoworked her way up in coding and is now working as a coding auditresponse specialist. Many students are interested in the many jobopportunities that are available to an experienced medical coder.Jennifer’s profile introduces students to one of those future careers anddescribes both the professional challenges and the everyday processesfor the coding audit response specialist. Encourage students to identify arealistic plan that will enable them to achieve professional goals at theappropriate time in their careers.3.Refer to Chapter 57 of this text for more information aboutcareers,professionalism, and patient relations.Learning Objective 1.2:Describe coding,HIPAA-mandated code sets, and coding skills. (Understand)Concepts for Lecture:1.Coding is the process of accurately assigning codes to verbaldescriptions ofpatients’ conditions and the health care services provided to treat thoseconditions.

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a.The health care system in the United States uses several distinct systemsof medical codes, called code sets, for different purposes.b.The various systems were developed by different organizations and followdifferent guidelines for their use.2.Accurate coding requires three major skills: abstracting, assigning, andarranging.a.To abstract, coders read the medical record and determine whichelements of the encounter require codes. They identify the reason for theencounter, diagnostic statements from the physician, complications andco-existing conditions, and the services provided.b.To assign codes, coders select codes that accurately describe theinformation documented in the medical record and accurately describe thepatient’s condition and services. Locate the Main Term in the Index, thenverify the code in the Tabular List. Each code must reflect the highest levelof specificity possible and contain the correct number of characters for thatcode.c.To arrange codes, coders must organize or sequence codes in a specificorder, based on the official coding guidelines and instructional notes.Codes that are not sequenced properly are not considered to be correct.Teaching NotesTeaching Resource:Pearson’s Comprehensive Medical Coding: A Path To Success, Chapter 1

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PowerPoint Lecture Slides for Chapter 1Tables:1-1HIPAA-Mandated Code SetsTeaching Notes/Tips:1.Stress that students do not need to memorizeindividual codes but shouldmemorize the rules and steps of the coding process.2.Show students copies of the coding manual for each of theHIPAA-mandatedcode sets.3.The termabstractalso describes a task in health information management inwhich inpatient coders review the medical record and cull data required forreporting, such as patient demographics and length of stay.Homework Assignment:Coding Practice, Exercise 1.1, What Is Coding?, #1–3Learning Objective 1.3:Explain how patient encounters relate to coding. (Understand)Concepts for Lecture:1.Coders assign diagnosis and procedure codes to a patientencounterafter ithas been completed, based on physician documentation.2.Patient encounters are generally classified by the location of the encounterbecause different coding and billing rules apply to each category.

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a.Outpatient encounters are physician interactions with patients who receiveservices and who have not been formally admitted to a health careinstitution, such as an acute care hospital, long-term care facility, orrehabilitation facility.b.Inpatient encounters are physician interactions with patients who havebeen formally admitted to a health care facility, such as an acute carehospital, long-term care facility, or rehabilitation facility.3.Each encounter generally involves three steps: diagnosis, treatment, anddocumentation.4.Establishing or updating a diagnosis involves a history, a physicalexamination, and testing.a.Refer to the Guided Example throughout this chapter to learn more aboutpatient encounters.b.The Guided Example of a Physician Diagnosis demonstrates howphysicians diagnose conditions.5.The treatment plan may include medication, surgery, lifestyle changes, ortherapy.a.Physicians may treat symptoms to provide relief to the patient until theydetermine the underlying cause.b.The Guided Example of a Treatment Plan demonstrates how physiciansdetermine the treatment plan.

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6.When physiciansdocumentthe encounter, they record the reason they sawthe patient, the diagnostic techniques used, tests or treatments planned, andtheir overall assessment of the patient.a.Physicians may treat symptoms to provide relief to the patient until theydetermine the underlying cause.b.The Guided Example of Documentation demonstrates how the patientencounter is documented.Teaching NotesTeaching Resource:Pearson’s Comprehensive Medical Coding: A Path To Success, Chapter 1PowerPoint Lecture Slides for Chapter 1Tables1-2Examples of Outpatient EncountersTeaching Notes/Tips:1.This text uses the terms “physician” and “provider” interchangeably to refer toany health care professional who provides services that are billed with ICD-10codes.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, thesurgeon, or the physical therapist.•Code for the diagnoses that describe why the patient received theseparticular services, but do not code for unrelated diagnoses.

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

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d.Certified Professional Coder–Apprentice (CPC-A®) certification is forcoders with less than 2 years of experience, or 1 year of experience inaddition to formal education.3.AHIMA has historically focused on hospital coders.a.Certified Coding Specialist (CCS) certification focuses on hospitalinpatient and outpatient coding.b.Certified Coding Specialist–Physician (CCS-P) certification focuses onphysician-based coding.c.The Certified Coding Apprentice (CCA) credential is geared toward entry-level coders with little or no job experience.Teaching NotesTeaching Resource:Pearson’s Comprehensive Medical Coding: A Path To Success, Chapter 1PowerPoint Lecture Slides for Chapter 1In-Class Activities:1.Invite anAAPCorAHIMAmember to talk to the class about certification andcareer progression.2.Refer again to the opening Professional Profile of Jennifer Holland. Discussthe 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 movingupward in her medical coding career?

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Teaching Notes/Tips:1.Encourage students to joinAAPCorAHIMAand participate in local chaptermeetings.2.Students are often intensely interested in the details of certification. Refer tothe Web sites ofAAPC(www.aapc.com) andAHIMA(www.ahima.org) forcurrent information on certification requirements for new graduates.Homework Assignment:Coding Practice, Exercise 1.3, Certification, #1–3Learning Objective 1.5:Summarize the career path andperformance expectations for a coding career.(Understand)Concepts for Lecture:1.Students are wise to begin learning about their career path and jobperformance expectations for accuracy and productivity.2.A career path is the progression of jobs and responsibilities throughout one’sworking life.a.Most coders look for an entry-level job upon graduation in order to gainbasic skills, become familiar with the health care field, and establishexcellent work habits.b.A mid-level job allows coders to expandtheir 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 anadvanced-level job, which requires a solid track record of goodperformance.d.When coders are ready to change jobs and advance their careers, theymay seek a new job internally, within their current organization, or theymay choose to look externally, for a job with a different company.3.Performance expectations are the outcomes employers need coders toachieve in order to demonstrate competence in the job.a.Coding jobs have high expectations because securing payment forservices from insurance companies requires a high degree of accuracyand 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, withcommon minimums of 30–40 words per minute (wpm) or 9,000–12,000keystrokes per hour (ksph).d.Case productionstandards, the number of cases to be coded each day,are based on the type of record being coded; whether coders areassigning diagnosis codes, procedure codes, or both; whether coderswork from paper or electronic charts; and what other responsibilities,suchas billing, coders do at the same time.Teaching NotesTeaching Resource:Pearson’s Comprehensive Medical Coding: A Path To Success, Chapter 1

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PowerPoint Lecture Slides for Chapter 1Tables:1-3Examples of Types of Organizations that May Require Coding Skills1-4Examples of Job Titles that MayRequire Coding Skills1-5Examples of a Coding Career PathIn-Class Activities:1.Refer to Table 1-3Examples of Types of Organizations that May RequireCoding Skills.2.Discuss the following question as a class or in small groups:•What are the names ofspecific organizations in your community that fallinto each category identified inthis table? For example, identify the namesof nearby hospitals, physician offices, and clinics.•If using small groups, divide the list into sections and assign each group adifferent section. Combine students’ suggestions into a list to which theycan refer and add as they begin job hunting.3.Refer again to the opening Professional Profile of Jennifer Holland. Discussthe 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 admissionsdepartment and career services department, you also look to codinginstructors for more specific information about the coding and billingprofession.2.Help students understand that in coding, like most careers, new graduates donot start at the top; they start at a basic leveland work their way up, withgreater responsibility and more skills at each level. Consider sharinghighlights of your own career path as an example.3.Take time to review Table 1-5 Examples of a Coding Career Path to helpstudents understand the variety of career opportunities available to them.4.Stress the importance of strong alphanumeric keyboarding skills. Manyemployers require a keyboarding test before they will conduct interviews withnew graduates. If possible, contact your career services department to learnwhat keyboarding rates are common for employers in your area.Homework Assignment:Coding Practice, Exercise 1.4, Coding Careers, #1–3CHAPTER 1 REVIEWConcepts for Lecture:1.Coding is the process of accurately assigning codes to verbal descriptions ofpatients’ conditions and the health care services provided to treat thoseconditions.

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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 patientencounters after theencounter is completed.4.Certification is a voluntary achievement that documents a coder’s havingattained a certain level of proficiency by passing a rigorous examinationoffered byAAPCorAHIMA.5.A career path is theprogression of jobs and responsibilities throughout one’scareer.6.Performance expectations are the outcomes employers need coders toachieve in order to demonstrate competence in the job.Teaching NotesTeaching Resource:Pearson’s Comprehensive Medical Coding: A Path To Success, Chapter 1Homework Assignment:Concept Quiz, Completion, #1–10Concept Quiz, Multiple Choice, #1–10

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

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•Instructor’s Manual with Lesson Plans•Chapter2PowerPoint Lecture•Chapter2Image LibraryDETAILED LESSON PLANSLearningObjective 2.1:Spell and define the key words, medical terms, and abbreviations relating toreimbursement.Concepts for Lecture:1.The key terms listed at the beginning of the chapter are important conceptsfor students to know, and appear in blue boldface type throughout thechapter.2.Students should also become familiar with the terms listed within tables in thechapter.3.Supplemental terms that appear in black boldface throughout the chapter aredefined in the glossary.Teaching NotesTeaching Resource:Pearson’s Comprehensive Medical Coding: A Path To Success,Chapter 2Page 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 impactsreimbursement so they can become valuable team members.Learning Objective 2.2:Describe the types of healthcare payers.Concepts for Lecture:1.Third-party payersareentities other than the patient or physician that pay forhealthcare services.Coders need to understand the various types of third-party payers because each has separate, and sometimes conflicting, rulesabout coding and billing.2.Health benefit plans funded by federal or state governments areentitlementprogramsfor whichbeneficiariesqualify based on specific criteria.a.Medicare is the single largest payer of healthcare services in the UnitedStates and pays for healthcare services for most people age 65 and over,people of any age with end-stage renal disease (ESRD), and people withdisabilities. Medicare offers four programs, called Part A, hospitalinsurance; 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 bythe federal government and one-third by state governments.

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c.Other government programs include Tricare, State Children’s HealthInsurance Program, and the Veteran’s Health Administration.3.Private health insurance is coverage for healthcare services offered by privatecorporations, such as Aetna, Cigna, or United Health Care, and not-for-profitorganizations, such as Blue Cross and Blue Shield.a.Group health plans are offered by employers and unions, which contractwith a private insurance company to provide a specific list of benefits totheir employees or members.b.Individual health insurance plans are those that people purchase directlyfrom a health insurance company, such as people who are self-employedor do not have benefits through an employer or government program.c.Workers’ compensationplans pay for medical costs due to employment-related injuries or illnesses, and vary from state to state.d.Automobile insurance policies often includemedicalpaymentsorpersonalinjury protection,which pays for medical expenses incurred during anautomobile accident.e.Managed care plans contract with physicians, hospitals, and otherproviders to offer services for a lower fee to health plans; then theycontract with private health insurance companies and self-insured plans topromote an exclusive network ofpreferred providersTeaching NotesTeaching Resource:Pearson’s Comprehensive Medical Coding: A Path To Success, Chapter2

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

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a.Payers establish medical necessity rules to avoid paying unscrupulousproviders who might provide a service just so they could receivepayments, rather than because the patient actually needs the service orwould benefit from it.2.Themedical recordis the comprehensive collection of all information on apatient at a particular facility.a.The diagnosis and procedure codes reported on the health insuranceclaim form or billing statement must be supported by information in themedical record for each encounter.b.Documentationis the written or electronic record of medical care andservices provided, and may refer to the overall medical record as well astoprogress notes.Teaching NotesTeaching Resource:Pearson’s Comprehensive Medical Coding: A Path To Success, Chapter2PowerPoint Lecture Slides:Tables:2-1Examples ofMedical Necessity Criteria2-2Elements of a Progress Note and Their Use in Coding2-3Elements of a Medical Record and Their Use in CodingFigures:2-1Example of a paper-based medical record.

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2-2Example of an electronic health record.In-Class Activities:Review the examples in Table 2-1. Discuss the following question as a class, insmall groups, or on an online discussion board:•What are other examples of appropriate and inappropriate medicalservices?Teaching Notes/Tips:Stress that coders should not manipulate codes in a way that distorts or altersthe diagnoses and procedures as documented in the medical record. Codersneed to be certain they are accurately describing everything that was done forthe patient and the reasons for which the services were provided.Homework Assignment:Coding Practice, Exercise 2.2, Documentation, #1–3Learning 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 insuranceclaim needs to becompleted in a timely and accurate manner in order forproviders to receive correct payment for their services2.Although providers do not code or bill for scheduling an appointment, theappointment begins when providers begin collecting insurance information.

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3.After completing registration information, a patient sees the physician and/orreceives the treatments and procedures needed. The physician documentsthe patient’s problem in a progress note and may check off services anddiagnoses on an encounter form orcharge slip.4.The encounter is coded based on a charge slip or information directly fromthe medical record; then the bill is prepared and submitted to the insurancecompany.5.When payers receive electronic claims, the computer system first performs afront-end edit check,which scans the claims for valid data including the policynumber, patient name, provider number, diagnosis codes, and procedurecodes.a.Arejected claimis one that is not accepted into the insurance company’scomputer system for processing due to missing or invalid data.b.Clean claimsare those which pass the front-end edit checks and have nomissing or invalid information. Most clean claims are processed usingautomatic adjudication, a process in which the computer automaticallydetermines benefits and payment.c.Some claims aresuspendedfrom the automatic process formanualreview in order to gather more information before payment is determined.d.After the payer has processed the claim, the provider receives a check orelectronic deposit and an EOB.e.If payment was denied for one service or for the entire claim, an accountsreceivable specialist needs to investigate the reason.

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f.After all insurance payments are received and follow-up is complete, theoffice sends the patient a bill forany deductible, coinsurance, or patientresponsibility amounts that have not been paid.Teaching NotesTeaching Resource:Pearson’s Comprehensive Medical Coding: A Path To Success, Chapter2PowerPoint Lecture Slides:Tables:2-1Coding Problems Causing Rejected or Denied ClaimsIn-Class Activities:As a class, or in small groups, create a flow chart that illustrates each step in thelife cycle of an insurance claim. Active participation and visualization helpstudents understand a complex process.Teaching Notes/Tips:1.Point out to students that the billing and coding procedures are not exactly thesame 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 byoffering to follow up on problem and unpaid claims. Positive financial resultsare almost always seen on claims that are reactivated. In addition, newcoders can learn a tremendousamount about coding and the paymentprocess by doing insurance follow-up.

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Homework Assignment:Coding Practice, Exercise 2.3, Life Cycle of an Insurance Claim, #1–3Learning Objective 2.5:Summarize the most common reimbursement methods for physicians, inpatienthospitals, and outpatient hospitals.Concepts for Lecture:1.The healthcare industry uses many different reimbursement or paymentmethods for services. The methods vary by type of payer; the setting, such asphysician’s office, outpatient hospital, or inpatient hospital; and the type ofservice. It is important to understand the terminology associated withreimbursement.a.Fee scheduleis a list of services with charges.b.Negotiated rate scheduleor adiscounted fee schedulespecify lower,reduced rates, or rates agreed upon by the payer and the type of setting.c.Prospective payment system(PPS) is a reimbursement method in whichpayment is made based on a predetermined fixed amount per case.d.Medicare uses the inpatient prospective payment system (IPPS).e.Medicare also uses the outpatient prospective payment system (OPPS).f.Capitationis a prospective payment system in which physicians are paid afixed amount per month for each member assigned to them, regardless ofwhether 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 (MPFS),updated annually.b.Medicare uses a resource-based relativevalue scale (RBRVS) toestablish reimbursement rates.c.A relative value unit (RVU) identifies the amount of work and expenseinvolved in providing a particular service.d.Geographic costs are also factored into the calculation ofRBRVS. This iscalled ageographic practice cost index(GPCI).e.Annualconversion factor(CF) is used to calculate the fees.3.Inpatient Hospital Reimbursementa.Inpatient hospitals are reimbursed based on fee schedules; per diempayment (an all-inclusive flat charge perday); and prospective payment.b.Diagnosis-related groups(DRGs) are the most common prospectivepayment system.Hierarchical condition category(HCC) coding furtherfine-tunes reimbursement.c.Best-knownDRGsare the Medicare severity-adjustedDRGs(MS-DRGs).d.Case-based paymentmeans that the rate is determined per case, or perinpatient admission.e.Cost outliersare unusual cases in which the cost is above or below astandard threshold amount established for the DRG.f.ADRG grouperis software that considers several clinical anddemographic characteristics of a patient.

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g.Hierarchical condition categorycoding (HCC) was developed to estimatefuture health risks and costs for Medicare Advantage and inpatients. Thefocus is to identify inpatients with chronic, high-cost illnesses, such ascertain types of cancer.4.Outpatient Hospital Reimbursementa.CMSOPPSassigns individual services to an ambulatory paymentclassification (APC) based on similar clinical characteristics and similarcosts.b.Private payers may adopt MedicareAPCs, modify them, establish theirown, or pay based on individual CPT codes.5.Reimbursement in other settings includes inpatient rehabilitation hospitals,ambulatory surgery centers, skilled nursingfacilities, home health agencies,and others.Teaching NotesTeaching Resource:Pearson’s Comprehensive Medical Coding: A Path To Success, Chapter2PowerPoint Lecture SlidesIn-Class Activities:Discuss the extensive terminology and the acronyms associated with thatterminology.Discuss the role Medicare andCMSplay in establishing fees andreimbursement.

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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 totalRBRVSvalue for aCPTcode by the annual conversion factor (CF). For example, a conversionfactor of $35 means that anRBRVSvalue of 1.0 is worth $35 on theMPFS.A code with anRBRVSvalue of 0.5 would be worth $17.50. A code with anRBRVSvalue of 2.0 would be worth $70. A code with anRBRVSvalue of 10.0would be worth $3,500. When Medicare adjusts prices each year, it publishesa new conversion factor that is applied to allCPTcodes.2.When discussingDRGgroupers, be sure to mention the seen variables,including principal diagnosis, secondary diagnosis, surgical procedures,complications and comorbidities, age and gender, discharge status, and trimpoints. Show the students an example. (An example of a MS-DRGisDRG375 Digestive Malignancy with Complication or Comorbidity. TheMDCfor thisDRGis MDC 06 Diseases and Disorders of the Digestive System.)Homework AssignmentCoding Practice Exercise 2.4, Reimbursement Methods, # 1-3Learning 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 receivereimbursement. Specific formats or forms are required in each healthcaresetting.2.After completingregistration information, a patient sees the physician and/orreceives the treatments and procedures needed. The physician documentsthe patient’s problem in a progress note and may check off services anddiagnoses on an encounter.3.Physicians bill services on theCMS-1500 form. The electronic format forclaims submission of physician services is the 837P.a.The National Uniform Claim Committee (NUCC) provides specificguidelines for completion.b.Items 1–13 are for patient and insuredinformation.c.Items 14–33 are for physician or supplier information.4.Inpatient hospitals bill services on the UB-04, also known as theCMS-1450.The electronic format is the 837I. The National Uniform Billing Committee (NUBC) maintains and updates this form.a.There are 81 form locators or boxes that must be completed. There arevery specific rules that apply to each locator.b.Instructions to complete the form are found on eitherwww.cms.govorwww.nubc.org.5.The UB-04/837I is used to bill the facility portion of outpatient services andtheCMS-1500 is used to bill for professional services.

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Teaching NotesTeaching Resource:Pearson’s Comprehensive Medical Coding: A Path To Success, Chapter2PowerPoint Lecture SlidesFigures:Figure 2-3 Example of a completedCMS-1500 claim form.Figure 2-4 Example of acompleted UB-04 form (with annotations).In-Class Activities:Have the students complete aCMS-1500 form based on a patient’s encounterform.As a group, have the students complete a UB-04 based on a patient’s hospitalstay.Teaching Notes/Tips:1.Electronic standards specify exactly how data is to be submitted, so thatpayers’ computers can read the information submitted by providers andclearinghouses.2.Discuss the “crosswalk” between the paper form and the electronic format.3.Go to the websitewww.nucc.org.4.Go towww.nubc.org.5.Carefully review the codes andinformation that populate the locators on theform UB-04.

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Homework Assignment:Coding Practice Exercise 2.5, Healthcare Claims, #1-5Learning 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 trackpatterns of billing, compare a physician’s fees with the average or norm, andtarget providers who deviate from the norm.a.If the insurance company or Medicare detects a pattern of overpaymentsdue toovercodingor improper billing, it can conduct anaudit.b.Fraudis knowingly billing for services that were never given or billing for aservice that has a higher reimbursement than the service actuallyprovided.c.Abuseis mistakenly accepting payment for items or services that shouldnot be paid for by Medicare, due to improper coding and billing practices.d.Compliancemeans following the rules established by multiple federal,state, and county government agencies.2.The Office of the Inspector General is a division of DHHS which investigatesfraud, abuse, and other noncompliance matters in the Medicare and Medicaidprograms.a.The federal False Claims Actimposes penalties on individuals andcompanies that defraud government programs.

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