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xi | |
Preface |
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xiii | |
How to Use This Text |
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xix | |
How to Use the Student Practice CD-ROM |
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xxi | |
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Health Insurance Specialist Career |
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1 | (12) |
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Health Insurance Overview |
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2 | (2) |
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4 | (1) |
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5 | (4) |
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9 | (4) |
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Introduction to Health Insurance |
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13 | (16) |
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What Is Health Insurance? |
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15 | (1) |
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Automobile, Disability, and Liability Insurance |
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15 | (3) |
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Major Developments in Health Insurance |
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18 | (1) |
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Health Insurance Coverage Statistics |
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18 | (11) |
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29 | (18) |
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History of Managed Health Care |
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30 | (4) |
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Managed Care Organizations |
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34 | (4) |
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38 | (3) |
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Consumer-Directed Health Plans |
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41 | (1) |
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Accreditation of Managed Care Organizations |
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41 | (2) |
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Effects of Managed Care on a Physician's Practice |
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43 | (4) |
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Life Cycle of an Insurance Claim |
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47 | (40) |
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Insurance Claim Life Cycle |
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48 | (12) |
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60 | (8) |
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Managing Established Patients |
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68 | (1) |
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68 | (4) |
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Maintaining Insurance Claim Files |
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72 | (3) |
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75 | (12) |
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Legal and Regulatory Issues |
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87 | (36) |
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Introduction to Legal and Regulatory Considerations |
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88 | (5) |
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Federal Laws and Events That Affect Health Care |
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93 | (7) |
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100 | (1) |
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100 | (1) |
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Health Insurance Portability and Accountability Act |
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100 | (23) |
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123 | (62) |
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125 | (2) |
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Outpatient Coding Guidelines |
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127 | (4) |
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131 | (4) |
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ICD-9-CM Index to Diseases |
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135 | (5) |
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ICD-9-CM Tabular List (Diseases) |
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140 | (8) |
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Index to Procedures and Tabular List |
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148 | (1) |
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ICD-9-CM Index to Diseases Tables |
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149 | (11) |
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Supplementary Classifications |
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160 | (3) |
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163 | (4) |
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Considerations to Ensure Accurate ICD-9-CM Coding |
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167 | (1) |
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ICD-10-CM: Diagnostic Coding for the Future |
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168 | (17) |
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185 | (62) |
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186 | (6) |
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CPT Categories, Subcategories, and Headings |
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192 | (3) |
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195 | (3) |
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198 | (10) |
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Coding Procedures and Services |
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208 | (2) |
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210 | (9) |
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219 | (1) |
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220 | (2) |
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Pathology/Laboratory Section |
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222 | (3) |
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Evaluation and Management Section |
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225 | (9) |
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Evaluation and Management Subsections |
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234 | (13) |
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247 | (12) |
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248 | (1) |
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HCPCS Level II National Codes |
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249 | (6) |
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Determining Payer Responsibility |
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255 | (1) |
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Assigning HCPCS Level II Codes |
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256 | (3) |
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CMS Reimbursement Methodologies |
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259 | (24) |
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Historical Perspective of CMS Reimbursement Systems |
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260 | (1) |
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260 | (1) |
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261 | (1) |
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Ambulatory Surgical Center Rates |
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262 | (1) |
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Clinical Laboratory Fee Schedule |
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263 | (1) |
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Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule |
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264 | (1) |
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Home Health Prospective Payment System |
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265 | (1) |
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Hospital Inpatient Prospective Payment System |
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265 | (3) |
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Hospital Outpatient Prospective Payment System |
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268 | (1) |
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Inpatient Psychiatric Facility Prospective Payment System |
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269 | (1) |
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Inpatient Rehabilitation Facility Prospective Payment System |
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269 | (2) |
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Long-Term Care Hospital Prospective Payment System |
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271 | (1) |
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Skilled Nursing Facility Prospective Payment System |
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272 | (1) |
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Medicare Physician Fee Schedule |
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273 | (10) |
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Coding for Medical Necessity |
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283 | (30) |
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Coding and Billing Considerations |
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288 | (3) |
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Coding from Case Scenarios |
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291 | (3) |
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Coding from Patient Records |
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294 | (19) |
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Essential CMS-1500 Claim Instructions |
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313 | (24) |
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Insurance Billing Guidelines |
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317 | (2) |
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Optical Scanning Guidelines |
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319 | (3) |
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Recovery of Funds from Responsible Payers |
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322 | (1) |
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Provider Identification Numbers |
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323 | (1) |
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Assignment of Benefits versus Accept Assignment |
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324 | (1) |
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Reporting Diagnoses: ICD-9-CM Codes |
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324 | (1) |
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Reporting Procedures and Services: HCPCS/CPT |
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325 | (3) |
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National Standard Employer Identifier Number |
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328 | (1) |
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Reporting the Billing Entity |
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329 | (1) |
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Processing Secondary Claims |
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330 | (1) |
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Common Errors That Delay Processing |
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331 | (1) |
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Final Steps in Processing Claims |
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332 | (1) |
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Maintaining Insurance Claim Files for the Practice |
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332 | (5) |
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337 | (18) |
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338 | (1) |
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339 | (10) |
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Commercial Secondary Coverage |
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349 | (6) |
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Blue Cross and Blue Shield Plans |
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355 | (28) |
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History of Blue Cross and Blue Shield |
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356 | (4) |
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Blue Cross/Blue Shield Plans |
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360 | (4) |
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Billing Information Summary |
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364 | (2) |
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366 | (8) |
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374 | (9) |
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383 | (46) |
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385 | (1) |
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386 | (2) |
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388 | (2) |
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390 | (1) |
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391 | (1) |
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392 | (1) |
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393 | (1) |
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Nonparticipating Provider Restrictions |
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394 | (2) |
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Surgical Disclosure Notice |
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396 | (1) |
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Mandatory Claims Submission |
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397 | (1) |
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398 | (1) |
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Advance Beneficiary Notice |
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398 | (2) |
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Experimental and Investigational Procedures |
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400 | (1) |
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Medicare as a Secondary Payer |
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400 | (4) |
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404 | (1) |
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404 | (3) |
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407 | (9) |
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Medicare with Medigap Claims |
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416 | (1) |
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Medicare-Medicaid Crossover Claims |
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417 | (1) |
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Medicare Secondary Payer Claims |
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418 | (3) |
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Roster Billing for Mass Vaccination Programs |
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421 | (8) |
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429 | (26) |
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430 | (4) |
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Medicaid Covered Services |
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434 | (2) |
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Payment for Medicaid Services |
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436 | (4) |
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Billing Information Notes |
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440 | (2) |
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CMS-1500 Claims Instructions |
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442 | (7) |
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Medicaid as Secondary Claims |
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449 | (1) |
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450 | (5) |
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455 | (30) |
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456 | (3) |
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459 | (1) |
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460 | (1) |
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461 | (4) |
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Tricare Programs and Demonstration Projects |
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465 | (1) |
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Tricare Supplemental Plans |
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466 | (1) |
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Tricare Billing Information |
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467 | (3) |
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470 | (8) |
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Primary Tricare with a Supplemental Policy |
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478 | (1) |
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Tricare as Secondary Payer |
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478 | (7) |
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485 | (152) |
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Federal Workers' Compensation Programs |
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486 | (2) |
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State Workers' Compensation Program |
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488 | (1) |
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489 | (1) |
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Classification of Workers' Compensation Cases |
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489 | (1) |
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Special Handling of Workers' Compensation Cases |
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490 | (1) |
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Workers' Compensation and Managed Care |
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491 | (1) |
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491 | (3) |
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494 | (2) |
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496 | (1) |
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496 | (1) |
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496 | (2) |
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498 | (11) |
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Appendix I Case Studies: Set One |
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509 | (22) |
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Appendix II Case Studies: Set Two |
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531 | (48) |
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579 | (8) |
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580 | (1) |
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581 | (1) |
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Insurance Plan Comparison Chart |
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582 | (1) |
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583 | (4) |
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Appendix IV Answers to Coding Exercises |
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587 | (12) |
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Answers to ICD-9-CM Coding Exercises (Chapter 6) |
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587 | (3) |
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Answers to CPT Coding Exercises (Chapter 7) |
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590 | (3) |
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Answers to HCPCS Coding Exercises (Chapter 8) |
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593 | (1) |
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Answers to Coding for Medical Necessity Exercises (Chapter 10) |
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594 | (5) |
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599 | (18) |
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Appendix VI Dental Claims Processing |
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617 | (10) |
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Appendix VII Abbreviations |
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627 | (4) |
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Appendix VIII Common Medical Terminology: Prefixes, Suffixes, and Combining Forms |
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631 | (2) |
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633 | (4) |
Bibliography |
|
637 | (4) |
Glossary |
|
641 | (22) |
Index |
|
663 | (30) |
Using the Student Practice CD-ROM |
|
693 | |