Congratulations!! FALL 2017 MEDICAL BILLERS! 

Medical Claims Class Resources

Presentations:

Course Intro and Syllabus Presentation Click here  HINT: Street Nam

Textbook Chapter 1 Click here

Powerpoint Chapter 1 Click here

Career Center Info Click here

Adult School Calendar Click here

Supplemental Homework Reading - Handout Part 1 Click here

Supplemental Homework Reading - Handout Part 2 Click here

Supplemental Homework Reading - Handout Part 3 Click here

Supplemental Homework Workbook- Handout Part 4 Click here

Supplemental Homework ICD-10 Example - Handout Part 5 Click here

Supplemental Homework ICD-10 Exercises - Handout Part 6 Click here

Supplemental Homework Abstracting Example - Handout Part 7 Click here

Index to Level II National HCPCS Codes 2016   Click here

Campus Map Click here

Indeed.com Job Search link Click here

Will You Be Replaced By a Robot?  Click here

Medicare MAC Claim Form Instructions  Click here

California Dept Workers Comp Claim Form Instructions  Click here

Great Article on Interviewing Medical Billers  Click here

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Code Books! 

For this course, you will need THREE books. The textbook you received and TWO codebooks for our coding exercises:

Please use the ISBN numbers to search for book sales online.  bookfinder.com or gettextbooks.com are excellent book search engines that find books for sale.

1)  ICD-10-CM (must be 10-CM!! Please do not buy ICD-10-PCS! It is NOT part of our course)


       ISBN: 978-1-62202-604-3, OR  ISBN: 978-1-62202-404-9, 

          OR  ISBN978-1-62202-212-0(Pick just ONE)



2) AMA CPT Professional  (either 2017 or 2016 - either is ok for classwork)

2017 or 2016 CPT Professional (Published by the AMA) 

978-1-62202-600-5

         ISBN: 978-1-62202-600-5, OR ISBN:  978-1-62202-400-1, 

              OR  ISBN: 978-1-62202-204-5 (Pick ONE)

If the codebook costs are a hardship, I will accept 2016 or even 2015 versions for the purposes of this class, although they cannot be used professionally any more. If you decide to use one of the older versions, please have it approved by me prior to purchase.

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Frequently Asked Questions

WHAT IS MEDICAL INSURANCE BILLING?

Our American healthcare system is extremely complicated and a medical billing clerk wears many, many hats!

Medical billing is a form of accounting with the added aspects of coding, complicated and very inconsistent insurance contracts, issues of medical ethics, state and federal regulations for handling of confidential records, strict laws governing the billing of taxpayer-funded programs such as Medicare and Medi-Cal, and a general knowledge of medical treatment, anatomy and medical terminology.

Medical billing specialists work in almost every type of healthcare facility, including hospitals, doctors' offices, skilled nursing facilities, and home health agencies, specialized medical billing outsource companies, and also as claims examiners/adjusters at medical insurance companies.

Job titles that may apply:

* Insurance Clerk

* Insurance Coder

* Medical Accounts Receivable Clerk

* Medical Biller

* Medical Billing and Coding Specialist

* Medical Billing Clerk

* Medical Billing Coder

* Medical Billing Specialist

* Medical Claims Examiner

* Medical Claims Adjuster

* Medical Coder

* Medical Coding Specialist

* Medical Insurance Biller

* Medical Insurance Clerk

* Medical Insurance Coder

* Medical Reimbursement Specialist

* Medical Voucher Clerk

* Patient Accounts Representative

* Patient Financial Representative

* Patient Service Representative

A medical biller is responsible for submitting the claims to insurance companies for payment to the provider for services rendered. The insurance company will either reject the claim and it can be resubmitted or they will approve the claim and pay the provider, if there is a remaining balance, the medical biller must then send a bill to the patient.   Medical coding translates diagnosis and service information into codes used by government programs and insurance companies and is sometimes done by the medical biller, and sometimes is a separate job function, which may require additional certification. 

The responsibilities of the medical biller may include some or all of the following:

* maintaining strict confidentiality in compliance with federal HIPAA and state laws.

* verifying patients’ insurance coverage

* using computer software to capture patient, insurance and financial information in a practice management database such as Medisoft

* knowing of insurance guidelines, especially Medicaid and Medicare as well as network procedures for HMO and PPO plans.

* managing the bill queue on a daily basis

* using coded data provider by the medical coders to produce and then submit claims to insurance companies for payment

* reviewing patient bills for accuracy and completeness and obtain any missing information

* submiting secondary billing in a timely manner with appropriate supporting documentation (when applicable)

* reviewing and appealing denied and unpaid claims

* calling insurance companies regarding any discrepancies in payments, if necessary

* working directly with the insurance company, the patient, and the healthcare provider, to get a claim processed and ultimately paid

* answering any questions patients may have about billing

* handling collections and unpaid accounts by establishing payment arrangements with patients, monitoring payments, and following up with patients if or when there is a lapse in payment

* getting in touch with collection agencies, figuring out if legal options should be pursued and testifying in hospital court cases, if needed

* managing the practice’s or facility’s Account Receivable reports

 

The medical coder’s responsibilities include:

* maintain strict confidentiality in compliance with federal HIPAA and state laws.

* use medical terminology and basic physiology knowledge to review paper charts and electronic health records to abstract or translate information into ICD-10-CM diagnosis codes and CPT/HCPCS procedure/supply codes

* apply procedure modifiers when appropriate

* identify all services that are billable

* identify services that are "bundled" into another services and may not be separately billed

* use either hard copy codebook manuals or a software encoder to find appropriate codes for diagnoses and services

* code accurately without downcoding or upcoding (downcoding undervalues services and costs the organization money, upcoding overvalues services and is considered fraudulent billing which can subject an organization to fines and sanctions)

* audit coding accuracy

* continually keep updated with quarterly and annual changes to the coding systems

* be compliant with payer coding rules, especially those established under the Medicare and Medicaid programs


Where can I work after completing this course?

This course prepares you mainly for physician office, billing service, insurance company or outpatient facility employment.  Job titles could include Medical Biller, Biller and Coder, Medical Receptionist, Insurance Clerk, Claims Processor, Claims Examiner, Insurance Eligibility Verification, Medical Collections, and similar job descriptions dealing with medical billing.  It does not specifically train for inpatient hospital billing and coding. 

Is there a certifying test at the end of the course or is a certificate given?

Upon completion of the Adult School course you will receive a certificate of completion.  You can also optionally take an entry-level certification examination called NCICS (National Certified Insurance and Coding Specialist) offered by the NCCT (National Center for Competency Testing).  This is at an additional cost.  NCCT provides testing certifications for those graduating from vocational programs, such as phlebotomy and medical assisting. Various school locations proctors the NCICS certification exam (ask your school or call NCCT for locations).  It certifies you have entry-level skills. Your course completion certificate also certifies entry-level skills. But the letters NCICS after your name looks impressive.  For details, see http://www.ncctinc.com/Certifications/

What is there above and beyond this class that can be done to advance my career?

With some job experience, students can study and certify for more advanced certifications, such as the AAPC's Certified Professional Coder (CPC) or study Health Information for various inpatient hospital records and coding positions.  Please see "Adavanced Certification" below.

What qualifications does the instructor have?

Thomas Fitzsimmons has passed the Nationally Certified Insurance and Coding Specialist (NCICS) certification exam through NCCT,  and is currently a Certified Professional Coder (CPC) through American Academy of Professional Coders (AAPC) and also a Registerred Health Information Technician (RHIT) through the American Health Information Management Association (AHIMA).  He has been received a Medical Coding Specialist Certificate and also an Associate in Science degree in Health Information Management from Santa Barbara City College.  He is a member of the Woodland Hills Chapter of the American Academy of Professional Coders (AAPC).  In addition to having consulted for small physician practices and billing services, he has coded and audited for the Ventura County Healthcare Agency, processed all types of medical claims for Blue Cross of California Individual Services, the Tenet Healthcare hospital chain, and for the claims administrator Meridian Healthcare Management.  As a claims consultant, he has worked for Kaiser Permanente, Motion Picture Health, and Blue Shield 65 Plus, and The Travelers Worker's Compensation to name a few.  He edited the Medicare provider newsletter and the Medicare Provider Billing Manual during his six years as a Training Specialist at Transamerica Occidental Medicare.  He has also taught Medical Insurance Billing and Health Claims Examining at American Career College, and Kaplan College in Panorama City.  He was a Long-Term Disability Benefits Determination Specialist at VPA, Inc. (now Sedgwick Claims).  

In the eight years he has taught at the Simi Valley Adult School and Career Institute he has certified over 300 students in Medical Insurance Billing.   

Can I work at home without experience?

"The Federal Trade Commission (FTC) has brought charges against promoters of medical billing opportunities for misrepresenting the earnings potential of their businesses and for failing to provide key pre-investment information required by law... The ads lure consumers with promises of substantial income working from home full- or part-time - "no experience required." They direct consumers to call a toll-free number for more information."

Click for > FTC FRAUD ALERT!

Technically, the answer is yes, but it's unlikely without experience.  Ask yourself, would you hire somebody with no job experience to work solo at home without supervision on sensitive protected medical information and accounts receivable money? There is a lot of financial and legal liability with medical care and patient accounting and medical records. How would you feel if your doctor let somebody with no experience take your medical information and your Social Security number home with them?

Also, the job market reality nowadays is that when an employer decides he or she can have work done "off-site" it usually is ending up off-shore in India or the Philippines.   Your best employment bet is to find employers who want the job done in the privacy and safety of their own facility.  Medical providers often hire somebody without job experience as an apprentice. Remember, doctors do internships, lawyers are law clerks and junior partners before they get their own law practice. For medical billing there is no law saying you need experience, but the liabilities are pretty high if confidential information is compromised, and the losses could be high if claims are not submitted timely, or are submitted in a manner that could appear fraudulent or abusive or counter to federal and state regulations.  Your being on-site actually helps maintain the integrity and privacy of the information.

What about advanced certification?

The AAPC (American Association of Professional Coders) offers a highly respected advanced certification called the CPC (Certified Professional Coder). AAPC has a student membership rate.  For more information see: http://www.aapc.com/certification/cpc.aspx

The CPC is beyond the scope of Adult School or Community Services Extension courses, as it is an advanced level exam, with many questions regarding coding, anatomy, government regulations and medical terminology. Obtaining a CPC is not easy for a beginner; there are some prep courses available and a study book by Carol Buck (CPC Coding Exam Review).

The AAPC will not award a full CPC to someone without at least two years of full-time job experience coding or a combination of a certificate of course completion and one year of experience coding. This is roughly what it takes to reach an intermediate level of proficiency. If you pass their exam with no experience (which is hard to do) they will award your certification as an "apprentice" level until you actually have the two years of full-time job experience or a year with a coding course completion certificate. Please visit their website if you need more information about them. To confirm your job experience they require a letter on employer letterhead confirming your job description and length of employment.

INPATIENT FACILITY CODING - Hospital Inpatient Coders make more money and, therefore, need more training and more credentials.  The certifications or credentials are issues by the American Health Information Management Association (AHIMA). 

The Certification for a beginning Hospital Coder is the Certified Coding Associate (CCA).  This is an entry-level skills certification, and would allo someone to enter the hospital coding arena as a beginner.   Do not let the word "entry-level" mislead you; only about 65% of those who took the CCA exam in the years 2007-2009 were able to pass the first time. (http://www.ahima.org/certification/cca/documents/2007_2009_CertificationExamPassRates.pdf)

The more comprehensive Hospital Coder certification is the Certified Coding Specialist (CCS), which demonstrates mastery of the hospital coding process.  This is a high-level test and should be completed only when you have taken courses in anatomy, medical terminology and have experience coding.   Of those taking the CCS exam in the year 2010, 48% passed the first time.  More info Click HERE

For more on AHIMA certification, please go to their website: http://www.ahima.org/certification/credentials.aspx

If you are specifically interested in programs that teach and certify inpatient hospital facility coding (Simi Adult is an entry-level program that does not teach to the level of Inpatient Facility Coding), you should find a school that is accredited by AHIMA's accreditation body, CAHIIM (Commission on Accreditation for Health Informatics and Information Management Education).   Local schools accredited to teach to AHIMA curriculum include:

Santa Barbara City College Health Information Management Program

CODEMED School of Professional Medical Coding

Please note these are both rigorous multi-disciplinary programs with courses in anatomy, physiology, pharmacology and information management as well as simply using code books.  They have roughly the same course outline, but SBCC's program is online distance learning, and is approximately 2,000 to 3,000 for coursework over at least two years.   CODEMED is located in the San Fernando Valley and has all-day Saturday classes for approximately 13 months at a cost or just under $10,000.   Here is a discussion of the SBCC program, other programs, ans AHIMA certifications:  http://www.indeed.com/forum/job/medical-coder/Medical-Coding-Specialist-Certificate-online-at-SBCC/t294058

CODER TEST STRATEGY SUGGESTIONS

With some strategy, it can be done! I recommend only skimming the long questions and underlining **critical information** in them. The priority should be on correctly answering ALL the shorter questions. For example, guess on the long questions and spend your time picking up the short answers and THEN go back to the long ones at the end--a question a page long with 5 codes is weighted the same as a three word true/false question, so it is points you are after. It helps sometimes to start from the end of the test and work backwards, as the hardest questions are mainly in the front of the test, and these questions can "burn you out" if you aren't careful.  Sometimes questions about anatomy may often be answered by looking up the terms in the code book indexes and viewing synonyms, where the code falls as far as code body system, and illustrations in the codebooks.

There is also no law saying you need to be certified. However, it indicates to clients and employers you have a certain level of competence. There are different levels of certifications. Your Adult School course completion certificate is one form of certification. It certifies you have skills suitable to qualify you for an entry-level position as a medical insurance clerk.  Some jobs specifically require certification. 

WHICH IS THE RIGHT SCHOOL FOR ME?

CLICK FOR SHORT DOCUMENTARY ABOUT STUDENT LOAN DEBT

" Americans 60 and older still owe about $36 billion in student loans, providing a rare window into the dynamics of student debt. More than 10 percent of those loans are delinquent. As a result, consumer advocates say, it is not uncommon for Social Security checks to be garnished or for debt collectors to harass borrowers in their 80s over student loans that are decades old."

http://www.washingtonpost.com/business/economy/senior-citizens-continue-to-bear-burden-of-student-loans/2012/04/01/gIQAs47lpS_story.html

If you have existing student loans, this may be helpful:

http://www.clarkhoward.com/how-public-service-career-can-erase-student?ecmp=clarkhoward_social_facebook_sfp

http://www.clarkhoward.com/how-public-service-career-can-erase-student?ecmp=clarkhoward_social_facebook_sfpLook at the course content and instructional hours of the courses and not by the verbal promises of their recruiters! Many private schools actually pay a sales commission to the recruiters for admitting students.  If they tell you you can code for a hospital and make $35 an hour and are not AHIMA/CAHIM accredited, they are misrepresenting the facts.  Please see "certification" above for suggestions on schools accredited to certify hospital coders.  

All programs are different in their hours, costs, structure and curriculum. It is very important that you find one that best suits your needs before making substantial time and money investments. The only way to do this is to compare the cost, the content and the reputation. Do not let a school sales-talk you into spending the equivalent of the price of a car without knowing what you are getting for that money. More money does not necessarily mean more education.

Please review this Department of Education announcement of new regulations of "for profit" schools that rely on student loan monies: http://www.ed.gov/news/press-releases/gainful-employment-regulations

Village Voice Article: "For-Profit Colleges Only a Con-Man Could Love" (please watch for scams!) Click Here
http://www.villagevoice.com/2012-08-01/news/for-profit-colleges-con/

The Simi Adult School course is an entry-level course in billing for physicians, health practitioners and medical equipment suppliers; it does not pretend to certify hospital coders.  The program is a single-semester course of 16-20 sessions, a total of 60 classroom hours, with a significant amount of reading and homework from the textbook and other exercises. In this course we learn fundamentals of the whole insurance process, the medical office structure, diagnosis coding, procedure coding, government regulations, balance billing, Workers Compensation, Medi-Cal, Medicare, Tricare, Managed Care, HMOs, PPOs, etc... A full semester could be taught on each of these subjects without exhausting the various complexities they present for a specialist. I could recommend various texts and internet resources for further study beyond the scope of our 15-18 sessions. 

DO I NEED TO BUY MEDISOFT SOFTWARE? HOW MUCH IS IT?

The Simi Valley Adult School does not sell software and it does not ask its students to purchase software. It does give a quick introduction on how to get a claim and a payment through the MediSoft software as an example on school lab computers.  You can obtain free demo versions of MediSoft for practice purposes.

Not all medical offices use MediSoft. There are other similar softwares out there. If you are interested in purchasing MediSoft, it can be obtained from the various vendors or from the manufacturer at www.medisoft.com/ If you just have to have it, MediSoft costs about $300 for the basic software. However, there are limitations to the $300 version of the software. It's best for small offices without a large number of patients and with only one computer. MediSoft Advanced runs more in the neighborhood of 2,500 +.  Another popular medical billing software is Lytec, which is made by McKesson, the same company that makes MediSoft.  Many provider offices now use a web-based claims clearing-house called Office Ally which is free unless you only bill Medicare.  It is supported by payments per claim by the insurance companies.  More information can be found at www.officeally.com.  Office Ally also has a web-based software that could be used instead of MediSoft or Lytec, but it is free and has limited software features.

DO I TAKE MEDICAL TERMINOLOGY CLASS FIRST, LAST OR CONCURRENTLY?

If you are a quick learner or have few other commitments, you can take them together. If you want to take them in separate semesters to give you more study time for each, you can do that instead in whatever order suits you.

You can take the medical terminology as a self-paced computer tutorial or as an instructor led semester-long lecture class. You can even buy a self-study workbook or take an online class. You have many options. But you must learn Medical Terminology to be a competent coder in the real world.

WHAT IS THE STARTING HOURLY WAGE WITHOUT EXPERIENCE?

Starting pay in medical office as a biller/coder varies. Without experience it would likely be in the range of $10-$16 per hour. You can check your local newspaper want ads, or look online www.indeed.com or www.craigslist.org to see what the opportunities are.

As an advanced level coder you could earn substantially more than a beginner. As an experienced and certified hospital coder you could earn $35+ an hour. However, hospitals do not have work from home positions, due to the complexity of the different departments reporting to the billing and coding areas and the confidentiality of records and the high dollar amount of the bills.

DO YOU OFFER JOB-PLACEMENT OR EXTERNSHIPS?

Employers in the community often send postings for entry-level jobs to your school.   These postings are on a bulletin board outside of the Business Office.  There are not always postings on the board, so it is a good idead to check periodically to see if a work request has come in.  Obviously, you should also be checking the internet and the local Employment Development Office to see if you can find employment, as well as checking the internet for listings (Indeed.com is very helpful).  Don't be afraid to network with other students.  At this time the school does not offer externships, but this could change in the near future.  If you are interested in unpaid work experience for resume purposes, you can explore various volunteer opportunities, and your instructor will give you a letter of recommendation and some paperwork to facilitate volunteer work.   Your instructor and the career center will do what they can to assist students, but it's up to each student to make job connections.  Some longer-term more expensive Medical Billing programs have more assistance with externship placement, so if this is vital to you, you might want to check out whether placement is offered by other programs such as Ventura College or Thousand Oaks Adult School.  If you have more time and lots of financial aid, you could also check out Everest College, De Vry and other private schools... make sure they are reputable!  Don't forget, if it sounds too good to be true, it usually is!!  If they tell you they guarantee you will leave their school with a $24 an hour job right away, you could be getting a sales pitch rather than real career counseling.

Recommended Publications for Additional Study at Home

If you would like to continue your study at home, I would recommend purchase of a CPT book and an ICD-9-CM book and a textbook-workbook.  Carol Buck's "Step-By-Step Medical Coding" is a very detailed look at coding, and Marilyn Fordney's "Insurance Handbook for the Medical Office" with its workbook gives much information about billing various insurance programs.   

Our class uses Joanne Valerius' excellent "Medical Insurance: An integrated Claims Process Approach" published by McGraw-Hill.  Valerius' book is well-written, comprehensive, and has an emphasis on what is necessary and practical, while it avoids the inaccuracies and useless trivia that mar most other texts dealing with health insurance.  This book has an optional workbook for students who want to do extra credit and get in more practice.  The textbook also has online quizzes and other online resources.  The class textbook is about $75.  Code books add another $150 in book charges.  You may be able to find used code books on the internet or borrow older code books for a deposit.  Our class is not long enough to cover all the chapters in the textbook, so we will cover the most pertinent and students may study other chapters at their leisure.

Once you have studied, you can take one of several national certification exams. The simplest and least expensive certification exam probably being the NCCT's Nationally Certified Insurance and Coding Specialist (NCICS). The website for NCCT is www.ncctinc.com


Copyright notice:  Materials presented on this website are protected by copyright law.  No distribution, sale or use without written permission of the copyright owners.  CPT is a registered trademark of the American Medical Association.  CPT coding instructions are given in order to comply with federal CMS billing regulations for HCPCS Levels I and II.  The actual CPT codes are the property of the AMA and purchase of an AMA licensed CPT code book for the appropriate service year is necessary for the use of these codes.  If any materials on this website have inadvertently been used without proper permission, the copyright owner need only contact the mediclaimclass at gmail to have the item removed.  All information in presented to the best of the webmaster's knowledge and the reader accepts liability for use of this information, which is provided free of charge to students and the billing community.

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