| Originator: | Hogue, Lori Status: Approved Department: MEA Medical Assistant |
| Date Created: | 11/12/2015 Submitted: 11/13/2015 Completed: 12/21/2015 |
| Effective Semester: | Fall |
| Catalog Year: | 2016-17 |
| Course Prefix: | MEA |
| Course Number: | 141 |
| Course Full Title: | Medical Billing |
| Reason for Evaluation: | Competencies Change Description Change |
| Current Credit: | 3 |
| Lecture Hours: | 3 |
| Lab Hours: | 0 |
| Clinical Hours: | |
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| If the credit hour change box has been marked, please provide the new credit hour: | |
| New Lecture Hours: | |
| New Lab Hours: | |
| New Clinical Hours: | |
| New Internship Hours: | |
| New Externship Hours: | |
| SUN Course?: | No |
| AGEC Course?: | No |
| Articulated?: | Yes |
| Transfer: | NAU |
| Prerequisite(s): | HES 113 |
| Corequisite(s): | none |
| Catalog Course Description: | An overview of medical insurance programs and the skills needed in handling insurance forms and insurance reports as applied to the medical office. Includes simulated computer data entry for patient records, procedures and diagnostic codes, insurance processing and electronic transmission of claims. |
| Course Learning Outcomes: | 1. Relate how HIPAA Electronic Health Care Transactions and Code Sets standards influence the electronic exchange of health information.(2,3,5,6)
2. Implement medical insurance specialists techniques to help ensure the financial success of physician practices. (2,3,5,6) 3. Appraise the impact of insurance policies upon medical billing. (2,3,5,6) 4. Appraise the impact of managed care and the referral process on the billing cycle.(2,3,5,6) 5. Perform entry level tasks using medical billing software to process claims with 100% accuracy. (2,3,5,6) 6. Explicate HIPAA laws and their impact upon the medical office.(2,3,4,5,6) |
| Course Competencies: | Competency 1 Differentiate between covered and non-covered services under medical insurance policies.
Objective 1.1 Compare indemnity and managed care approaches to health plan organization. Objective 1.2 Outline examples of cost containment employed by health maintenance organizations. Objective 1.3 Determine how a preferred provider organization works. Objective 1.4 Identify the two elements that are combined in a consumer-driven health plan. Objective 1.5 Sequence the ten steps in the medical billing cycle. Competency 2 Determine the importance of accurate documentation when working with medical records. Objective 2.1 Determine the steps needed to complete the medical billing process. Objective 2.2 Compare the intent of HIPAA and ARRA/HITECH laws. Objective 2.3 Assess the purpose of the HIPAA Privacy Rule. Objective 2.4 Examine the purpose of the HIPAA Security Rule Objective 2.5 Determine the purpose of the HITECH Breach Notification Rule Objective 2.6 Distinguish how the HIPAA Electronic Health Care Transactions and Code Sets standards influence the electronic exchange of health information. Objective 2.7 Determine how to guard against potentially fraudulent situations. Objective 2.8 Identify how various organizations enforce HIPAA Objective 2.9 Outline the benefits of a compliance plan Competency 3 Determine the method used to classify patients as new or established. Objective 3.1 Outline the five categories of information required of new patients. Objective 3.2 Examine how information for established patients is updated. Objective 3.3 Determine patients' eligibility for insurance benefits. Objective 3.4 Assess the importance of requesting referral or preauthorization approval. Objective 3.5 Determine primary insurance for patients who have more than one health plan. Objective 3.6 Summarize the use of encounter forms. Objective 3.7 Identify the eight types of charges that may be collected from patients at the time of service. Competency 4 Determine the purpose and organization of ICD-10-CM Objective 4.1 Outline the structure, content and key conventions of the Alphabetic Index. Objective 4.2 Outline the structure, content and key conventions of the Tabular List. Objective 4.3 Implement the rules for outpatient coding that are provided in the ICD-10-CM official Guidelines for Coding and Reporting. Objective 4.4 Analyze the content of Chapters 1 through 21 of the Tabular List. Objective 4.5 Assign correct ICD-10-CM diagnosis codes Objective 4.6 Differentiate between ICD-9-CM and ICD-10_CM Competency 5 Determine the correct use of the CPT code set Objective 5.1 Outline the organization of CPT Objective 5.2 Summarize the use of format and symbols in CPT Objective 5.3 Assign modifiers to CPT codes Objective 5.4 Outline the six steps for selecting CPT procedure codes to patient scenarios. Objective 5.5 Determine how the key components are used in selecting CPT Evaluation and Management codes. Objective 5.6 Identify the physical status modifiers and add-on codes used in the Anesthesia section of CPT Category I codes. Objective 5.7 Differentiate between surgical packages and separate procedures in the Surgery section of CPT Category I codes. Objective 5.8 Determine the purpose of the Radiology section of CPT Category I codes. Objective 5.9 Code for laboratory panels in the Pathology and Laboratory section of CPT Category I codes. Objective 5.10 Code for immunizations using Medicine section CPT Category I codes. Objective 5.11 Contrast Category II and Category III codes. Objective 5.12 Determine the purpose of the HCPCS code set and its modifiers. Competency 6 Appraise major strategies that help ensure compliant billing. Objective 6.1 Examine the importance of code linkage on healthcare claims. Objective 6.2 Determine the use and format of Medicare's Correct Coding Initiative (CCI) edits and medically unlikely edits (MUEs). Objective 6.3 Identify types of coding and billing errors. Objective 6.4 Determine the use of audit tools to verify code selection. Objective 6.5 Assess the fee schedules that physicians create for their services. Objective 6.6 Compare the methods for setting payer fee schedules. Objective 6.7 Calculate RBRVS payments under the Medicare Fee Schedule. Objective 6.8 Compare the calculation of payments for participating and nonparticipating providers. Objective 6.8 Determine how balance billing regulations affect the charges that are due from patients. Objective 6.9 Differentiate between billing for covered versus non-covered services under a capitation schedule. Objective 6.10 Outline the process of patient check out. Objective 6.11 Outline the use of real-time claims adjudication tools in calculating time-of-service payments. Competency 7 Distinguish between the electronic claim transaction and the paper claim form. Objective 7.1 Examine the content of the patient information section of the CMS-1500 claim. Objective 7.2 Compare billing provider, pay-to-provider, rendering provider, and referring provider. Objective 7.3 Examine the content of the physician or supplier information section of the CMS-1500 claim. Objective 7.4 Determine the hierarchy of data elements on the HIPAA 837P claim. Objective 7.5 Categorize data elements into the five sections of the HIPAA 837P claim transaction. Objective 7.6 Evaluate the importance of checking claims prior to submission, even when using software. Objective 7.7 Compare the three major methods of electronic claim transmission. Competency 8 Assess the major features of group health plans regarding eligibility, portability, and required coverage. Objective 8.1 Compare employer-sponsored and self-funded health plans. Objective 8.2 Examine provider payment under the various private payer plans. Objective 8.3 Contrast health reimbursement accounts, health savings accounts, and flexible savings (spending) accounts. Objective 8.4 Determine the major private payers Objective 8.5 Analyze the purpose of the five main parts of participation contracts. Objective 8.6 Outline the information needed to collect copayments and bill for surgical procedures under contracted plans. Objective 8.7 Distinguish the use of plan summary grids. Objective 8.8 Prepare accurate private payer claims. Objective 8.9 Determine how to manage billing for capitated services. Competency 9 Prepare Medicare primary claims with 100% accuracy Objective 9.1 Determine eligibility requirements for Medicare program coverage. Objective 9.2 Differentiate among Medicare Part A, Part B, Part C, and Part D. Objective 9.3 Contrast the types of medical and preventive services that are covered or excluded under Medicare Part B. Objective 9.4 Assess the process that is followed to assist a patient in completing an ABN from correctly. Objective 9.5 Calculate fees for nonparticipating physicians when they do and do not accept assignment. Objective 9.6 Outline the features of the Original Medicare Plan. Objective 9.7 Determine the features and coverage offered under Medicare Advantage plans. Objective 9.8 Identify the coverage that Medigap plans offer. Objective 9.9 Analyze Medicare, Medical Review (MR), recovery auditor, and ZPIC plans. Competency 10 Prepare Medicaid claims with 100% accuracy. Objective 10.1 Determine the purpose of the Medicaid program. Objective 10.2 Assess the income and asset guidelines used by most states to determine eligibility. Objective 10.3 Evaluate the importance of verifying a patient's Medicaid enrollment. Objective 10.4 Identify the services that Medicaid usually does not cover. Objective 10.5 Outline the types of plans that states offer Medicaid recipients. Objective 10.6 Determine the claim filing procedures when a Medicaid recipient has other insurance coverage. Competency 11 Prepare TRICARE and CHAMPVA claims with 100% accuracy. Objective 11.1 Determine the eligibility requirements for TRICARE. Objective 11.2 Compare TRICARE participating and non-participating providers. Objective 11.3 Determine how the TRICARE Standard, TRICARE Prime, and TRICARE Extra programs differ. Objective 11.4 Analyze the TRICARE for Life program. Objective 11.5 Determine the eligibility requirements for CHAMPVA. Competency 12 Determine the four federal workers' compensation plans. Objective 12.1 Identify the two types of state workers' compensation benefits. Objective 12.2 Assess work-related injuries. Objective 12.3 Outline three responsibilities of the physician of record in a workers' compensation case. Objective 12.4 Differentiate between Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). Competency 13 Determine the claim adjudication process. Objective 13.1 Outline the procedures for following up on claims after they are sent to payers. Objective 13.2 Assess a remittance advice (RA). Objective 13.3 Identify the points that are reviewed on an RA. Objective 13.4 Outline the process for posting payments and managing denials. Objective 13.5 Outline the purpose and general steps of the appeal process. Objective 13.6 Assess how appeals, post-payment audits, and over-payments may affect claim payments. Objective 13.7 Determine the procedures for filing secondary claims. Objective 13.8 Examine procedures for complying with the Medicare Secondary Payer (MSP) program. Competency 14 Determine the structure of a typical financial policy. Objective 14.1 Examine the purpose and content of patients' statements and the procedures for working with them. Objective 14.2 Compare individual patient billing and guarantor billing. Objective 14.3 Assess the responsibilities for each position that is typically part of billing and collections. Objective 14.4 Outline the processes and methods used to collect outstanding balances. Objective 14.5 Identify two federal laws that govern credit arrangements. Objective 14.6 Determine the tools that can be used to locate unresponsive or missing patients. Objective 14.7 Outline the procedures for clearing uncollectible balances. Objective 14.8 Analyze the purpose of a retention schedule. Competency 15 Create primary claims for twenty patient encounters using Medisoft. Objective 15.1 Prepare a claim for each patient encounter based on abstracting information from case studies. Objective 15.2 Prepare correct claims by selecting the correct ICD-10-CM and CPT codes for the encounter, abstracting information from case studies. Objective 15.2 Examine claims for errors or omissions. Objective 15.3 Perform the process for editing claims and adding attachments to electronic claims. Objective 15.4 Perform the proper procedure for editing and deleting charges. Objective 15.5 Verify ICD-10-CM and CPT codes link correctly. Competency 16 Create secondary claims working with RAs Objective 16.1 Determine the steps to submit a secondary claim Objective 16.2 Examine the procedure for handling denied claims Objective 16.3 Differentiate between Medicare RAs and and a commercial payer RAs and preparing secondary claims. Objective 16.4 Calculate patient balances. Competency 17 Distinguish between inpatient and outpatient hospital services. Objective 17.1 Determine the steps relating to hospital billing and reimbursement. Objective 17.2 Contrast coding diagnoses for hospital inpatient cases and for physician office services. Objective 17.3 Determine the coding system used for hospital procedures. Objective 17.4 Outline the factors that affect the rate that Medicare pays for inpatient services. Objective 17.5 Distinguish hospital healthcare claim forms. Competency 18 Create patient accounts in Medisoft. Objective 18.1 Perform data entry of Patient Information. Objective 18.2 Perform the steps for entering, editing and deleting charges in patient accounts. Objective 18.3 Enter payments received from insurance carriers. Objective 18.4 Enter insurance adjustments and capitation payments. Objective 18.5 Create, edit and print statements. Objective 18.6 Enter patient co-pays and deductibles to patient accounts. |