This course covers the fundamentals of medical billing, coding, and reimbursement by explaining how all of these components work together.
Emphasis will be placed on the practical application of the latest industry knowledge and standards, with the goal of helping those who work with medical claims and claims data stay ahead of the game.
Participants will learn about the following:
- The claim flow process from registration through adjudication and payment
- How physicians and hospitals set and manage charges
- Critical data elements on the two major claim forms and what they mean
- How and why the major coding systems are utilized
- How various reimbursement methods are used by payors
AAPC Continuing Education Units Available.
This program meets AAPC guidelines for 6.0 Core A continuing education units.
Section 1: Life Cycle of a Claim
- Setting charges – the hospital chargemaster and clinic fee schedule
- Process by which a claim is generated, from registration through discharge, and the role that each department plays in that process
- Important data elements on the UB04 and CMS-1500 and what they mean
- Role of the claims clearinghouse
- How payors adjudicate and pay claims
- How providers receive and post payments
- The back end: appeals, denials, adjustments, subrogation, etc.
Section 2: Coding
- How each coding system works
- When and why they're used
- How they affect charges and reimbursement
- CPT, HCPCS codes
- Diagnosis Related Groups (DRGs) and Major Diagnostic Categories (MDCs)
- Ambulatory Patient Classifications (APCs)
- ICD-10 diagnosis and procedure codes
Section 3: Reimbursement Explained
Who Will Benefit:
- Prospective Payment Systems: DRG and APC based reimbursement
- Typical hospital contracting structures: per diem, per stay, carve outs, case rates, minimum/maximums, etc.
- Physician fee schedules and fee maximums, RBRVS, RVUs and capitation
- Major payor types (Medicare, Medicaid, HMO, PPO, ACO, etc.) and how they reimburse providers
- Health Information Managers
- Medical Billers
- Physicians and other Medical professionals
- Provider Contract Managers
- Medical Coders
- Claim Examiners
- Reimbursement Directors
- Payment Integrity Managers
- Quality Managers and Revenue Managers