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Comprehensive Health Insurance: Billing, Coding, and Reimbursement, 3rd edition

Published by Pearson (May 1, 2017) © 2018

  • Deborah Vines
  • Ann Braceland
  • Elizabeth Rollins
  • Susan Miller

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For introductory courses in medical billing and coding.

A how-to guide to key health insurance concepts

Comprehensive Health Insurance: Billing, Coding, and Reimbursement equips students for medical administrative tasks, from submitting claims and verifying benefits to posting payments and appealing claim denials. Using a step-by-step approach, it covers the foundations and interconnection of insurance, billing, coding and reimbursement. Case studies and patient files contextualize and simplify the complexities of health care.

The 3rd Edition includes 2017 ICD-10, CPT and HCPCS codes. It assesses the impact of the Affordable Care Act, while examining health care trends such as care delivery models and innovation driven by competition.

Hallmark features of this title

Practical skill-building

  • Step-by-step organization, across chapters, takes students through each stage of the medical billing process. Chapters build upon one another to connect concepts.
  • Examples and professional tips reinforce best practices in billing and coding.
  • Crucial HIPAA material is detailed in Chapter 4, ensuring familiarity with this “need to know” law.

Active-learning opportunities

  • Hands-on practice exercises help students master skills, retain information and stay engaged.
  • Case studies with critical-thinking questions offer glimpses into real-world scenarios, while honing decision-making skills.
  • Chapter objectives, introductions, summaries and reviews help students build comprehension and focus their studies.

New and updated features of this title

Trends in health care

  • UPDATED: Highlighted trends in health care include care delivery models, innovation driven by competition, new technologies, rising costs and an expansion of patients, both insured and uninsured.
  • UPDATED: Discussions of the Affordable Care Act touch on the bill’s impact on insurance and billing, as well as the Medicaid expansion program (Ch. 13).
  • NEW: Concierge medicine and telemedicine are explored as new methods of healthcare treatment and cost savings.

Updated practice and resources

  • UPDATED: 2017 ICD-10, CPT and HCPCS codes are drawn on throughout all coding content and exercises. Chapter 5 addresses revisions to ICD coding that add specificity to patient health problems.
  • UPDATED: The new CMS-1500 form is reviewed in detail. All related exercises and examples include the 02-2012 form, the standard Medicare and Medicaid claim form required by CMS.
  • EXPANDED: New figures and tables illustrate key concepts, helping students make connections between important ideas.

Highlights of the DIGITAL UPDATE for MyLab Health Professions for Comprehensive Health Insurance (available for Spring 2024 classes)

Instructors, contact your sales rep to ensure you have the most recent version of the course.

  • 2023 UPDATE: Minor updates to ICD-10 codes, where required, were made in anticipation of the ICD-11 implementation. In addition to appearing in MyLab, these updates are also available in the Pearson+ eTextbook and in new versions of print books and student workbooks published following these updates. But page numbers and educator resources remain the same.

Features of MyLab Health Professions for Comprehensive Health Insurance for the 3rd Edition; published 2017

  • Pre-test, post-test, review and homework help students gauge their understanding of chapter concepts and identify areas to work on.
  • CMS-1500 and UB-04 exercises offer practice with actual forms used in the medical office.
  • Activities for CPT, Benefits & Payment and Refunds & Appeals case studies help students think through and apply information critically.
  • Auto-graded practice AAPC CPC and AHIMA CCA certification exams are modeled after actual exam blueprints. Upon completing exams, students receive feedback and rationales for each question.
  • Gradebook gives you detailed insight into each student’s progress. With this data, you can intervene as needed to help the class stay on track.
  • Pearson+ eTextbook lets students choose how they learn best. Part of your MyLab course, Pearson+ merges easy-to-use eTextbooks with study tools.

SECTION I: A CAREER IN HEALTH CARE

  1. Introduction to Professional Billing and Coding Careers

SECTION II: THE RELATIONSHIP BETWEEN THE PATIENT, PROVIDER, AND CARRIER

  1. Understanding Managed Care: Insurance Plans
  2. Understanding Managed Care: Medical Contracts and Ethics
  3. Introduction to the Health Insurance Portability and Accountability Act (HIPAA)

SECTION III: MEDICAL CODING

  1. ICD-10-CM Medical Coding
  2. Introduction to CPT and Place of Service Coding
  3. Coding Procedures and Services
  4. HCPCS and Coding Compliance
  5. Auditing

SECTION IV: MEDICAL CLAIMS

  1. Physician Medical Billing
  2. Hospital Medical Billing

SECTION V: GOVERNMENT MEDICAL BILLING

  1. Medicare Medical Billing
  2. Medicaid Medical Billing
  3. TRICARE Medical Billing

SECTION VI: ACCOUNTS RECEIVABLE

  1. Explanation of Benefits and Payment Adjudication
  2. Refunds, Follow-Up, and Appeals

SECTION VII: INJURED EMPLOYEE MEDICAL CLAIM

  1. Workers’ Compensation

APPENDICES

  1. Completing the CMS-1500 Form for Physician Outpatient Billing
  2. Completing the CMS-1500 Form for Physician Outpatient Billing Plus Determining the Correct Diagnostic and Procedure Codes
  3. Completing the UB-04 Form for Hospital Billing
  4. Medical Forms
  5. Acronyms and Abbreviations
  6. Medical Terminology Word Parts
  7. Helpful Websites

About our authors

Deborah Vines has worked extensively for over 30 years in the healthcare industry as a practice administrator and manager in physical therapy, dermatopathology and pediatrics. She has also held management positions in the hospital setting. As director of operations for a national healthcare staffing corporation, she has traveled across the United States, working directly with physicians and medical human resources personnel to secure jobs for individuals in the medical billing, coding and collection fields. One of Ms. Vines’s mentionable achievements is that in one fiscal year, through mentoring and training, she assisted 300 recruits to find employment in the medical billing industry. This achievement led her to open the Allied Career Center in Dallas, Texas, a successful vocational school specializing in medical office specialist training.

Ann Braceland, NCICS, has been working in the medical field since graduating from Gwynedd Mercy College with an associate’s degree in nursing science. As a practice manager, her extensive work in managed care and medical billing and coding has allowed her to research and find means of informing others through her teaching of the changes and challenges that arise in the medical field. Mrs. Braceland has established and managed satellite offices in physical and occupational medicine. She is a Medicare representative with a vast spectrum of knowledge that she uses to train staff and physicians in compliance coding and billing. As director of training for the instructors of Allied Career Center in Dallas, Texas, her presentation of the material for students led to the publication of this book. Mrs. Braceland is a National Certified Insurance and Coding Specialist.

Susan Miller has worked in the health care industry for 25 years, managing and supervising medical billing processes. She has lectured in a classroom setting, providing students with knowledge and skills on medical billing and coding. Ms. Miller continues her health care career in medical billing, providing support to staff members on billing and coding guidelines.

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