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Preface
Medical insurance plays an important role in the financial well-being of every
health care business. The regulatory environment of medical insurance is evolving
faster than ever. Changes due to health care reform require medical office professionals to acquire and maintain an in-depth understanding of compliance, electronic health records, medical coding, and more.
The seventh edition of Insurance in the Medical Office: From Patient to Payment emphasizes the medical billing cycleten steps that clearly identify all the components
needed to successfully manage the medical insurance claims process. Studying this
cycle shows how administrative medical assistants must first collect accurate patient
information and then be familiar with the rules and guidelines of each health plan in
order to submit proper documentation and follow up on payments. This ensures that
offices receive maximum, appropriate reimbursement for services provided. Without
an effective administrative staff, a medical office would have no cash flow!
So, why is studying medical insurance especially important for Medical Assisting
students? Medical Assistants (MAs) have the ability to work both clinically and administratively in the physician practice. This flexibility makes them valuable members of
the health care team. With the unpredictable nature of the economy, many practices are
doing more with less. This means that MAs may find themselves in a position where
they are working in a clinical capacity and also asked to assist with billing tasks. Furthermore, knowing about insurance, billing, and reimbursement is not only important
for MAs in the workforce, but this knowledge is also required for certification. Insurance
in the Medical Office is specifically targeted to Medical Assisting students and addresses
the role they play in contributing to the financial success of the medical office.

Organization of Insurance in the


Medical Office, 7e

Copyright 2014 The McGraw-Hill Companies

Here is an overview of the chapters, including how they relate to the steps of the
medical billing cycle:
Chapter

Coverage

Chapters 1, 2, 3

Covers Steps 1 through 4 of the medical billing cycle by introducing the major types of medical insurance,
payers, and regulators, as well as the medical billing cycle. Also covers HIPAA/HITECH Privacy, Security,
and Electronic Health Care Transactions/Code Sets/Breach Notification rules.

Chapters 4, 5, 6

Covers Steps 5 and 6 of the medical billing cycle, while building skills in correct coding procedures, use of
coding references, and compliance with proper linkage guidelines.

Chapters 7, 8, 9, 10, 11, 12

Covers Step 7 of the medical billing cycle and the general procedures for calculating reimbursement,
how to bill compliantly, and preparing and transmitting claims. Describes the major third-party private
and government sponsored payers procedures and regulations, along with specific filing guidelines.

Chapter 13

Covers Steps 8 through 10 of the medical billing cycle by explaining how to handle payments from payers,
follow up and appeal claims, and correctly bill and collect from patients.

Chapter 14

Provides necessary background in hospital billing, coding, and payment methods.

Chapter 15 (available at
www.mcgrawhillcreate.com)

Covers dental insurance for those programs that include it.

Chapter 16 (available at
www.mcgrawhillcreate.com)

Covers ICD-9 and ICD-10 as an alternative to Chapter 4 for those programs still early in their transition from
ICD-9 to ICD-10.

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New to the Seventh Edition


One of the first things you may notice, if you are familiar with earlier editions of
From Patient to Payment, is that the seventh edition has been tailored to the
specific needs of medical assistants as they handle office administration tasks.
Content and coverage are updated and refocused to provide a practical, targeted
overview of medical insurance and billing. To that end, the title has been updated
to better reflect the new content of the book. The new title is thus Insurance in
the Medical Office: From Patient to Payment.
The new seventh edition has benefited from the extensive teaching experience
with Medical Assisting students that new co-author Nikita Carr brings to the
project.
The new edition is now designed around the current medical billing cycle that
follows the overall medical billing and documentation cycle used in Practice Management and Electronic Health Records environments and applications. Groups of
chapters sequentially cover the major sections of that cycle, followed by exercises to
apply the skills needed in each section.
Because of the mandate to the health care industry to adopt ICD-10-CM/PCS
on October 1, 2014, students must work toward expertise using this coding system.
For this reason, with the seventh edition of this book, ICD-10 is the primary diagnostic coding system taught and exemplified in Insurance in the Medical Office. An
alternate to Chapter 4 on ICD-9-CM (Chapter 16) is provided through McGrawHills Create system for additional study if the instructor elects to cover it in more
depth.
Starting in Chapter 3, in-chapter Exercises give students the opportunity to get
hands-on experience with key Practice Management Program tasks through simulations of real software. Completing on-the-job tasks relating to PMPs is an important aspect of a medical assistants work. Insurance in the Medical Office offers options
for completing these tasks:
Connect Plus Connect Plus provides simulated Medisoft exercises in four
modes: Demo, Practice, Test, and Assessment. The exercises simulate usage of
Medisoft Advanced Version 17. The simulated exercises, offered online, cover
key practice management tasks to provide experience in working with patient,
insurance, procedure, diagnosis, claims, and transaction databases. If assigned
this option, students should read Appendix A, Guide to Medisoft, as the first
step, and then follow the instructions that are p
printed in each chapters
Connect Plus Exercises, indicated with the
logo.

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
Insurance in the Medical Office or printed out from a PDF file on the books
Online Learning Center, www.mhhe.com/newbycarr), 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 electronic CMS1500 form, access either the HTML or Adobe Form Filler form at the books
Online Learning Center, www.mhhe.com/newbycarr. See Appendix B, The Interactive Simulated CMS-1500 Form, for further instructions.
Connect Plus If you are assigned to use Connect Plus for these exercises, Connect Plus also provides simulated CMS-1500 exercises in four modes: Demo,
Practice, Test, and Assessment. In this version, some data may be pre-populated
to allow the students to focus on the key tasks of each exercise. These simulations
are auto-graded.

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Copyright 2014 The McGraw-Hill Companies

Many of the exercises involve insurance claims. These specific exercises may be
completed one of three ways:

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Key Content Changes


Pedagogy
Learning Outcomes are restated to reflect the revised version of Blooms Taxonomy and the range of difficulty levels to teach and assess critical thinking
about medical insurance and coding concepts.
Major chapter heads are now structured to reflect the numbered Learning
Outcomes.
In addition to the listing of learning outcomes and the listing of key terms, each
chapter opener displays the Medical Billing Cycle, with the steps relevant to that
chapter highlighted.
Key terms are now defined in the margins for easy reference, while also being
listed in the Glossary toward the end of the book.
Billing Tips and Compliance Guidelines highlight key concepts or provide additional tips to help students navigate through the material.
Thinking It Through questions have been added at the end of each section to
assess each Learning Outcome.
New Chapter Summaries have been created in a tabular, step-by-step format
with page references to help with review of the material.
End-of-chapter elements are now tagged with Learning Outcomes.
The Chapter Review section includes:
Using Terminology matching questions with key terms and definitions.
Checking Your Understanding multiple choice and short answer questions.
Applying Your Knowledge cases.

Copyright 2014 The McGraw-Hill Companies

Chapter-by-Chapter
Chapter 1: New key termsaccounts payable (AP), cash flow, certification,
coding, documentation, electronic health record (EHR), health information
technology (HIT), medical assistant, medical billing cycle, medical documentation and billing cycle, out of pocket, PM/EHR, revenue cycle management
(RCM), statement, third-party payer. Chapter now focuses on the medical assistants role in revenue cycle management and clinical workflow; new coverage of
health information technology and practice management programs; updated
medical billing cycle; chapter now highlights the importance of certification and
continuing education.
Chapter 2: New key termsabuse, audit, breach, breach notification, business
associate (BA), Centers for Medicare and Medicaid Services (CMS), code set,
covered entity (CE), designated record set (DRS), electronic data interchange
(EDI), encounter, encryption, medical standards of care, Office of E-Health
Standards and Services (OESS), Office of Inspector General (OIG), password,
transaction. New coverage and discussion on the Affordable Care Act and the
Health Information Technology for Economic and Clinical Act (HITECH).
Chapter 3: New to this edition, this chapter focuses on the patient encounter
and billing information. Simulated chapter exercises include creating a new patient account, updating an existing patient account, verifying patient eligibility,
and entering a patients insurance information.
Chapter 4: (Chapter 3 in the previous edition) Updated for ICD-10. New Key
termscombination code, diagnostic statement, eponym, exclusion notes,
GEM, ICD-10-CM, ICD-10-CM Official Guidelines for Coding and Reporting, inclusion notes, Index to External Causes, laterality, manifestation, NEC
(not elsewhere classified), Neoplasm Table, nonessential modifier, NOS (not otherwise specified), outpatient, placeholder character (x) sequelae, seventhcharacter extension, Table of Drugs and Chemicals, Z Code. Simulated chapter
exercise covers entering a patients diagnosis.

Preface

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Chapter 5: (Chapter 4 in the previous edition) New key termseponym, key


component, moderate sedation, place of service (POS), resequenced, section
guidelines, separate procedure. Updated steps for locating correct CPT codes.
Simulated chapter exercise covers entering a patients procedure and charge.
Chapter 6: (Chapter 5 in the previous edition) New key termsaccept assignment,
adjustment, bundled payment, conversion factor, financial policy, flexible saving account (FSA), health reimbursement account (HRA), health savings account (HSA),
high-deductible health plan (HDHP), independent practice association (IPA), meaningful use, Medicare Physician Fee Schedule (MPFS), partial payment, per member
per month (PMPM), real-time claims adjudication (RTCA), self-pay patient. Chapter is focused on check-out procedures. Simulated chapter exercises cover entering a
patients copayment in the PMP, billing for supplies, and creating a walkout receipt.
Chapter 7: (Chapter 6 in the previous edition) New key terms5010 format,
CMS-1500 (02/12), secondary claim, tertiary claim. Expanded coverage of electronic claims transmission. Coverage of secondary claims transmission. Simulated chapter exercises cover completing a CMS-1500 form, submitting claims
electronically, and completing a secondary claim.
Chapter 8: New key termscarve out, Consolidated Omnibus Budget Reconciliation Act (COBRA), credentialing, elective surgery, Employee Retirement Income
Security Act of 1974 (ERISA), family deductible, group health plan (GHP), individual deductible, individual health plan (IHP), late enrollee, maximum benefit
limit, monthly enrollment list, open enrollment period, precertification, rider, selfinsured health plan, stop loss provision, utilization review, utilization review organization (URO), waiting period. Simulated chapter exercises cover completing a
primary payer claim and completing a Blue Cross Blue Shield primary payer claim.
Chapter 9: New key termshealth insurance claim number (HICN), InternetOnly Manuals (IOM), Medicare Integrity Program (MIP), Medicare Learning
Network (MLN), Medicare Secondary Payer (MSP), Physician Quality Reporting System (PQRS), urgently needed care. Step by step instructions on filling
out the ABN. Simulated chapter exercise covers completing a Medicare claim.
Chapter 10: New discussion on the expected impact of the Affordable Care Act
on the Medicaid program. Simulated chapter exercises cover completing a Medicaid claim.
Chapter 11: New key termscatchment area, Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS). Simulated chapter exercise
covers completing a TRICARE claim.
Chapter 12: New coverage of automobile and disability insurance. New key
termsAdmission of Liability, automobile insurance policy, disability compensation programs, independent medical examination (IME), lien, Notice of Contest, Occupational Safety and Health Administration (OSHA). Simulated chapter
exercise covers completing a workers compensation claim.
Chapter 13: (Chapter 7 in the previous edition) New key termsadjustment
code, aging, autoposting, bad debt, collections, cycle billing, day sheet, development, electronic remittance advice (ERA), Equal Credit Opportunity Act
(ECOA), explanation of benefits (EOB), Fair Debt Collection Practices Act
(FDCPA) of 1977, guarantor billing, NSF checks, overpayment, patient refund,
reconciliation, Telephone Consumer Protection Act of 1991, Truth in Lending
Act, upcoding. Expanded coverage of collection regulations and procedures. Coverage of NSF checks. Simulated chapter exercises cover posting an insurance payment, generating a patient statement, and writing off an uncollectible account.
Chapter 14: (Chapter 15 in the previous edition) New key terms comorbidities,
complications, ICD-10-PCS. Expanded coverage of the Medicare Inpatient and
Outpatient payment systems.
For a detailed transition guide between the sixth and seventh editions, visit www.
mhhe.com/newbycarr.
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Preface

Copyright 2014 The McGraw-Hill Companies

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Insurance in the Digital WorldSupplementary


Materials for the Instructor and Student
Instructors, McGraw-Hill knows how much effort it takes to prepare for a new
course. Through focus groups, symposia, reviews, and conversations with instructors like you, we have gathered information about what materials you need in order
to facilitate successful courses. We are committed to providing you with highquality, accurate instructor support. Knowing the importance of flexibility and
digital learning, McGraw-Hill has created multiple assets to enhance the learning
experience no matter what the class format: traditional, online or hybrid. This revision is designed to help instructors and students be successful with digital solutions
proven to drive student success.

A one-stop spot to present, deliver, and assess digital


assets available from McGraw-Hill: McGraw-Hill
Connect Insurance in the Medical Office

Looking for more material on


coding? The Medical Coding
Workbook for Physician Practices
& Facilities, ICD-10 Edition
(0073511048, 9780073513713)
provides practice and instruction
in coding and compliance skills.
The coding workbook reinforces
and enhances skill development
by applying the coding principles
introduced in Insurance in the
Medical Office, 7e and extending
knowledge through additional
coding guidelines, examples, and
compliance tips.

McGraw-Hill Connect Insurance in the Medical Office provides online


presentation, assignment, and assessment solutions. It connects your students with
the tools and resources theyll need to achieve success. With Connect you can deliver assignments, quizzes, and tests online. A robust set of questions and activities,
including all of the end-of-section and end-of-chapter questions, interactives, the
in-chapter exercise simulations and Testbank questions, are presented and aligned
with the textbooks learning outcomes. As an instructor, you can edit existing questions and author entirely new problems. Track individual student performanceby
question, assignment, or in relation to the class overallwith detailed grade reports. Integrate grade reports easily with Learning Management Systems (LMS),
such as Blackboard, DesiretoLearn, or eCollegeand much more. Connect Plus
Insurance in the Medical Office provides students with all the advantages of
ConnectMedical Assisting plus 24/7 online access to an eBook. This mediarich version of the book is available through the McGraw-Hill Connect platform
and allows seamless integration of text, media, and assessments. To learn more, visit
http://connect.mcgraw-hill.com.

Copyright 2014 The McGraw-Hill Companies

A single sign-on with Connect and your Blackboard


course: McGraw-Hill Higher Education and Blackboard
Blackboard, the Web-based course management system, has partnered with
McGraw-Hill to better allow students and faculty to use online materials and activities to complement face-to-face teaching. Blackboard features exciting social
learning and teaching tools that foster active learning opportunities for students.
Youll transform your closed-door classroom into communities where students remain connected to their educational experience 24 hours a day. This partnership
allows you and your students access to McGraw-Hills Connect and McGraw-Hill
Create right from within your Blackboard courseall with one single sign-on.
Not only do you get single sign-on with Connect and Create, you also get deep integration of McGraw-Hill content and content engines right in Blackboard.
Whether youre choosing a book for your course or building Connect assignments,
all the tools you need are right where you want theminside of Blackboard. Gradebooks are now seamless. When a student completes an integrated Connect assignment, the grade for that assignment automatically (and instantly) feeds your
Blackboard grade center. McGraw-Hill and Blackboard can now offer you easy access to industry leading technology and content, whether your campus hosts it or
we do. Be sure to ask your local McGraw-Hill representative for details.
Preface

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Create a textbook organized the way you teach:


McGraw-Hill Create
With McGraw-Hill Create, you can easily rearrange chapters, combine material
from other content sources, and quickly upload content you have written, like your
course syllabus or teaching notes. Find the content you need in Create by searching
through thousands of leading McGraw-Hill textbooks. Arrange your book to fit
your teaching style. Create even allows you to personalize your books appearance
by selecting the cover and adding your name, school, and course information. Order
a Create book and youll receive a complimentary print review copy in 35 business
days or a complimentary electronic review copy (eComp) via e-mail in minutes. Go
to www.mcgrawhillcreate.com today and register to experience how McGraw-Hill
Create empowers you to teach your students your way. Create is your resource for
including Chapters 15 and/or 16 in your book. Visit the website or contact your
sales rep for more information. www.mcgrawhillcreate.com

Record and distribute your lectures for multiple


viewing: My LecturesTegrity
McGraw-Hill Tegrity records and distributes your class lecture with just a click
of a button. Students can view anytime/anywhere via computer, iPod, or mobile
device. It indexes as it records your PowerPoint presentations and anything shown
on your computer so students can use keywords to find exactly what they want to
study. Tegrity is available as an integrated feature of McGraw-Hill Connect
Insurance in the Medical Office and as a standalone.

Instructors Resources

Supplement

Features

Instructors Manual (organized by Learning Outcomes)

Lesson Plans
Answer Keys for all exercises
Documentation of Steps and Screenshots for Simulated Medisoft and CMS-1500 Exercises

PowerPoint Presentations
(organized by Learning
Outcomes)

Key Terms
Key Concepts
Teaching Notes

Electronic Testbank

EZ Test Online (Computerized)


Word Version
Questions have tagging for Learning Outcomes, Level of Difficulty, Level of Blooms Taxonomy, Feedback,
ABHES, CAAHEP, CAHIIM, and Estimated Time of Completion.

Tools to Plan Course

Medisoft Exercises
Resources

McGraw-Hill Guide to Success for Insurance in the Medical Office


Technical Support Information
Steps for those students completing the simulated exercises in Connect Plus

CMS-1500 and UB-04 Forms

Electronic versions of both forms

xii

Preface

Correlations of the Learning Outcomes to Accrediting Bodies such as ABHES CAAHEP, and CAHIIM
Sample Syllabi
Conversion Guide between sixth and seventh editions
Asset Mapre-cap of the key instructor resources, as well as information on the content available through
Connect Plus

Copyright 2014 The McGraw-Hill Companies

You can rely on the following materials to help you and your students work through
the material in the book, all of which are available on the books website, www.mhhe.
com/newbycarr (instructors can request a password through their sales representative):

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Need help? Contact McGraw-Hills Customer Experience Group (CXG). Visit


the CXG website at www.mhhe.com/support. Browse our FAQs (Frequently Asked
Questions), product documentation, and/or contact a CXG representative. CXG is
available Sunday through Friday.
Want to learn more about this product? Attend one of our online webinars. To
learn more about the webinars, please contact your McGraw-Hill sales representative. To find your McGraw-Hill representative, go to www.mhhe.com and click
Find My Sales Rep.

About the Authors


Cynthia Newby, CPC, CPC-P, has worked with educational programming across
her career, first with the McGraw-Hill Community College Division, then moving
to a business/industry information technology training firm, and currently as
founder and president of Chestnut Hill Enterprises, Inc., a textbook development
company with over twenty years of proven programs. Cynthia is the author or managing director of many McGraw-Hill programs, including Medical Insurance, Insurance in Medical Offices, Medical Coding Workbook, Hospital Billing, and Computers in the
Medical Office. Interests include community-based volunteering and gardening;
Cynthias Lagniappe Garden in Roxbury, CT, has been featured on the national
Garden Conservancy Open Garden Days tour and in national magazines.

Copyright 2014 The McGraw-Hill Companies

Nikita Carr, CPC, has instructed and developed curricula for medical assisting
and medical billing and coding programs in a variety of academic settings. Nikita
has taught in the Adult Education program for Chesterfield County Public Schools
and coordinated the Medical Billing and Coding Specialist program at the Centura
College, Midlothian, Virginia, campus. Nikita has worked with the Allied Health
Division of McGraw-Hill in the production of several billing, insurance, and coding titles. Prior to her educational career Nikita worked over fifteen years in health
care clinically and administratively for hospitals, long-term care facilities, and physician practices.

Preface

xiii