Medical Billing Curriculum

You will be instructed on the difference between HMO and PPO plans, and develop a full understanding of the differences between group insurance plans and individual health plans. Additionally, you will learn how to work with both client healthcare providers and insurance providers in order to address and satisfy a patients’ medical needs.
Health Insurance Models include:
• Medicare Eligibility and Guidelines
• Medicaid Eligibility and Guidelines
• TRICARE
• Consumer Driven Health Plans (CDHP)
• Workers’ Compensation and Liability
• Role of Primary Care Providers and Physician Credentialing

In this section of the curriculum, you will learn the chronological healthcare process commencing with the patient making an initial appointment through the final issuing of the medical bill. All facets of the appointment are important for a Medical Biller to understand. This will enable you to have a clear understanding of all codes entered into the billing system.
Patient Registration Process and Data Capture includes:
• Scheduling an Appointment
• Insurance Coverage Validation
• Obtaining Demographics
• Patient Registration
• Generated Encounter Forms
• Medical Visits
• Authorization Forms
• Patient Check-Out and Discharge
• Entering Charges
• Claims Generation and Submitting Claims
• Consent for Payment

Medical coding and billing has experienced an explosive revolution over the last decade. Previously coders learned and practiced in ICD-9 (International Classification of Diseases, 9th edition) which listed around 13,000 various medical codes. But, with the launch of ICD-10 (International Classification of Diseases, 10th edition) the list of codes expanded to 63,000 and continues to grow. This makes coders who are proficient in ICD-10 far more marketable and in demand. In the following section you will learn the basics of understanding the ICD-10 coding system and later expand upon this knowledge.
The Introduction to ICD-10 Includes:
• Codebook Structure
• ICD-10-CM Alphabetic Index
• IDC-10-CM Conventions
• ICD-10-CM Official Guidelines for Coding and Reporting
• General Coding Guidelines
• Externship Causes of Morbidity
• Factors Influencing Health Status and Contact with Health Services

CPT® (Current Procedural Terminology) Codes are provided by the American Medical Association (AMA). This code platform provides professional healthcare industries with a universal code that all providers are able to understand. CPT® codes are listed in 3 categories; services, performance measures, and emerging technologies. In addition, CPT® codes are also included in the Healthcare Common Procedure Coding System (HCPCS).
CPT® Concepts includes:
• CPT® Code Selection
• Evaluation and Management Codes
• Anesthesia Codes
• Surgery Codes
• Radiology Codes
• Laboratory Codes
• Medicine Codes
• Modifiers

The Healthcare Common Procedural Coding System (HCPCS) was developed by the Centers for Medicare and Medicaid. This system is a 3-level coding system which allows primary practices to understand codes provided from state funded medical faculties.
HCPCS Level II includes:
• HSPSC Level II Codes
• Types of Codes
• HSPCS Level II Reimbursement
• HSPCS Level II National Modifiers
• Ambulance Origin and Destination Modifiers
• Reporting for Discarded Drugs and Medications

Medical necessity is the level of care approved for a physician to treat within the realm of necessity to the patients’ health and wellbeing. When reviewing this topic you will review what level of necessity the Social Security Act, or Medicare, and the AMA deem as important medical practice and those that are considered unnecessary. What this will determine is if a patient will receive a treatment or not, which depends on how serious the medical situation is.
Medical Necessity includes:
• National Correct Coding Initiative (NCCI)
• Modifiers and NCCI Edits
• National Coverage Determinations and Local Coverage Determinations
• CPT® and HCPCS Codes

Claim Forms are used to report medical procedures to a clients’ insurance company. While studying this section you will learn the difference between critical documents that must be utilized to report the treatment that a patient has received.
Claim Forms includes:
• National Uniform Claim Committee
• CMS-1500 Detailed Information
• UB-04 (CMC 1450) Detailed Information

The importance of proper billing cannot be stressed enough. In this section you will review the importance of comprising an accurate bill, making sure it is delivered to the appropriate parties and the necessity of proper documentation. While creating a bill seems simple enough, Medical Billers must have acute attention to detail and patience while navigating through the various codes listed by medical practitioners.
Billing includes:
• Fee Schedules
• Data Entry
• Reduced Payment Delay
• Prior Authorization
• Claims Scrubbers
• A/R Deposit Balancing
• Technology and Claims Submission
• Audits
• Hospital Facility Billing
• Primary and Secondary Insurance

Accounts receivable (A/R) is used to manage payments that must be made to the healthcare practice. In this section of study, you will learn how to verify insurance, check insurance availability, review authorization and process claims and billing submissions. In addition to learning about A/R, you will also study collections concepts.
A/R and Collection Concepts Includes:
• Explanation of Benefits and Remittance Advice
• A/R Management
• Denials and Appeals
• Patient Statements
• Refunds
• Patient Collection Practices
• Bankruptcy Concepts

The following section reviews the various government carriers who supply medical care to individuals. These government carriers are known as Medicare, Medicaid and TRICARE. While this information has been explained previously, this section will review the various carriers and provide a more detailed explanation of the services. In this section you will learn how a patient may qualify for a carrier, what standard practices offer and the benefits that come with each carrier.
Government Carriers includes:
• Medicare and Medicaid Claims Filing Requirements
• Medicare and Medicaid Completion Guidelines
• TRICARE Claims Processing
• RBRVS and RVU Concepts

Blue Cross Blue Shield is a nationwide insurance company who is able to work with Medicaid. In this section you will review the various services and benefits utilized with Blue Cross Blue Shield.
Blue Cross Blue Shield includes:
• Common Insurance Types
• Contractual Requirements
• Claim Filing Requirement
• Explanation of Benefits
• Common Denials and Appeals

Commercial Insurance Carriers are private for-profit insurance companies. This means that the company is able to collect revenue from its clients while still providing an insurance break for those insured through the commercial carrier. In this section you will learn about the practices and necessary requirements for these services. In addition, you will learn the various methods to provide information and filing claims.
Commercial Insurance Carriers includes:
• Common Denials and Rejections
• Appeals and the Affordable Care Act
• Appeals and Denials

Workers compensation is used when an employee is injured while on the job. It is generally the responsibility of the company to pay for any lost wages and medical care for the injury. These companies are also able to hire an insurance agency who will take on the additional cost. During this section you will review and learn methods for billing either the company or insurance company that is in charge of the patients’ care.
Workers’ Compensation includes:
• Occupational Safety and Health Administration (OSHA)
• Coverage and Provider Reimbursement
• Claims Completion