Medical Billing Syllabus

Medical coding is the process of translating healthcare services, procedures, diagnoses, and equipment into standardized alphanumeric codes. These codes are used for various purposes, including billing, insurance claims, and statistical analysis. The coding system helps healthcare providers, insurance companies, and government health agencies communicate information about medical services consistently and accurately.

Two main coding systems are widely used in medical coding:

1. International Classification of Diseases (ICD):
- ICD codes are used to represent diagnoses and medical conditions.
- These codes provide a standardized way of classifying diseases and health conditions.

2. Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS):
- CPT and HCPCS codes are used to represent medical procedures, services, and supplies.
- CPT codes are maintained by the American Medical Association (AMA), while HCPCS codes are managed by the Centers for Medicare and Medicaid Services (CMS).

Here's how the medical coding process typically works:

1. Patient Encounter:
- A patient visits a healthcare provider for a consultation, treatment, or other medical services.

2. Documentation
- The healthcare provider documents the details of the patient encounter, including diagnoses, procedures performed, and any relevant information.

3. Code Assignment:
- A medical coder reviews the documentation and assigns appropriate codes based on the standardized code sets (ICD, CPT, HCPCS).

4. Billing and Claims Submission:
- The coded information is used for billing purposes, and the codes are included in insurance claims submitted to payers.

5. Insurance Processing:
- Insurance companies use the codes to process claims, determine reimbursement, and assess the medical necessity of services.

6. Statistical Analysis:
- Aggregated coded data is used for statistical analysis, research, and public health purposes.

Accurate and consistent medical coding is crucial for ensuring proper reimbursement, facilitating communication among healthcare professionals, and generating reliable healthcare statistics. Medical coders play a vital role in the healthcare industry by helping maintain standardized and organized health information.

• RCM Cycle 
• Collecting & Entering Data 
• Paper Claims Processing 
• Electronic Claims Processing 
• Posting Payments 
• Generating Reports 
• Billing Your Clients 

• The Basics of the CMS 1500 Form 
• Box by Box Breakdown of the CMS 1500 Form 
• Step-By-Step Instructions for Completing a CMS 1500 
• Online CMS Form Completion Exercises 
• Billing Tips 
• Commonly Made Errors 

The Life Cycle of an Insurance Claim 

• Definition 
• Proper Usage 
• Resource & Reference Material 

• Group Health 
• Individual Policies 
• Medicare 
• Medicaid 
• Auto Insurance 
• Workers Compensation 
• Tricare 

• Insurance Claim Processing 
• Claim Payment 
• Report Generation 

• Essential Office Forms 
• Patient Demographic Form and Completion 
• Insurance Cards 
• Insurance Verification Form and Verification Procedures 
• Superbill 
• Day sheet
• Examining Insurance Cards 
• Insurance Verification Process 
• Mock Insurance Verification Conversations 
• Insurance Verification Exercise

• Definition 
• Proper Usage 
• Resource & Reference Material 

Calculating Co-payments & Deductibles 

Billing Identification Numbers 

Basic Components of Billing Applications

• Clinic Data
  • Billing Identification Numbers
  • Physician Data
    • Tax ID, UPIN, License Numbers
    • Assignment
  • Patient Data
    • Demographics Information
    • Insurance Information
    • Procedure Information
    • Diagnosis Information

• Patient Demographics 
• Guarantor Information & Handling 
• Insurance Coverage Information 
• Patient Condition Information 
• Patient Treatment Information 
• Clinic Billing Information 

• Paper Claims 
• Electronic Claims 
• Secondary Claims 
• Claims Attachments 

The Life Cycle of an Insurance Claim 

• Tax ID, UPIN, License Numbers 
• Assignment 

• Charge Entry 
• Payment Entry 
• Financial Adjustments 
• Transaction Notes 
• Electronic & Paper Claims 
• Calculating Co-paymentss & Deductibles 
• 100 Co-payments & Deductibles Problems & Answers 
• Appeals & Adjudication 
• Fraud & Abuse 
• Tips for Successful Workers Compensation Claim Filing & Handling 

• Full Payment 
• Partial Payment 
• Deductible 

• Demographics Information 
• Insurance Information 
• Procedure Information 
• Diagnosis Information 

FINAL EXAMINATION