1
Front Matter
5 chapters2
Part I: Foundations: The System, the Money, and the Rules
7 chapters- Part I — Foundations: The System, the Money, and the Rules
- Chapter 1: The Revenue Cycle: How Healthcare Gets Paid, From Patient Check-In to Final Payment
- Chapter 2: Healthcare Reimbursement: Insurance Types, Payer Contracts, Fee Schedules, and Who Pays What
- Chapter 3: Medicare, Medicaid, and the Government Payers: The Rulebook Everyone Else Copies
- Chapter 4: Medical Records and Documentation: The Clinical Foundation of Every Code
- Chapter 5: Compliance and Ethics: Fraud, Abuse, HIPAA, and Why Accuracy Is a Legal Obligation
- Chapter 6: The Coder's and Biller's Toolkit: Code Books, Software, Resources, and Workflow
3
Part II: Diagnosis Coding: ICD-10-CM
7 chapters- Part II — Diagnosis Coding: ICD-10-CM
- Chapter 7: ICD-10-CM Structure: Chapters, Categories, Codes, and the Logic of Disease Classification
- Chapter 8: Finding the Code: The Alphabetic Index, the Tabular List, and Why You Never Code from Memory
- Chapter 9: ICD-10-CM Official Guidelines: The Rules That Decide Which Code Is Right
- Chapter 10: Coding Common Conditions: Infectious Disease, Neoplasms, Endocrine, Blood, Mental Health, and the Nervous System
- Chapter 11: Coding Complex Cases: Circulatory, Respiratory, Digestive, Musculoskeletal, Genitourinary, and Pregnancy
- Chapter 12: The Special Chapters: Injuries, Poisonings, External Causes, Signs and Symptoms, and Z-Codes
4
Part III: Procedure Coding: CPT
8 chapters- Part III — Procedure Coding: CPT
- Chapter 13: CPT Structure: Sections, Guidelines, Symbols, and the Anatomy of a Code
- Chapter 14: Modifiers: The Two Digits That Change the Claim
- Chapter 15: Evaluation and Management I: The Office Visit and the 2021 Rewrite
- Chapter 16: Evaluation and Management II: Hospital, Observation, Consultations, Critical Care, and the Emergency Department
- Chapter 17: Surgery Coding I: The Surgical Package, Global Periods, Integumentary, and Musculoskeletal
- Chapter 18: Surgery Coding II: Respiratory, Cardiovascular, Digestive, Urinary, Maternity, and Nervous System
- Chapter 19: Radiology, Pathology and Laboratory, and Medicine: The Non-Surgical Sections
5
Part IV: HCPCS, Edits, and the Price of a Service
5 chapters- Part IV — HCPCS, Edits, and the Price of a Service
- Chapter 20: HCPCS Level II: Supplies, Equipment, Drugs, and the Codes CPT Doesn't Cover
- Chapter 21: NCCI Edits and Bundling: What Pays Together, What Doesn't, and Why Unbundling Is a Federal Case
- Chapter 22: Medical Necessity: NCDs, LCDs, ABNs, and Proving the Service Was Needed
- Chapter 23: Pricing the Service: RVUs, the Medicare Physician Fee Schedule, and the Chargemaster
6
Part V: Billing: From Encounter to Claim
6 chapters- Part V — Billing: From Encounter to Claim
- Chapter 24: Patient Access: Registration, Eligibility, Prior Authorization, and the Front-End Fixes
- Chapter 25: The CMS-1500: Completing the Professional Claim Field by Field
- Chapter 26: The UB-04: Completing the Institutional Claim, Revenue Codes, and Bill Types
- Chapter 27 — Electronic Claims Submission: Clearinghouses, EDI, the ANSI 837, and the Digital Pipeline
- Chapter 28 — Payment Posting: Remittance Advice, EOBs, Allowed Amounts, and Reading What You Actually Got Paid
7
Part VI: Getting Paid: Denials, Appeals, and Accounts Receivable
5 chapters- Part VI — Getting Paid: Denials, Appeals, and Accounts Receivable
- Chapter 29 — Denial Management: Why Claims Get Denied, How to Fix Them, and How to Prevent Them
- Chapter 30 — Appeals: When the Payer Says No and You Know They're Wrong
- Chapter 31 — Accounts Receivable: Aging, Work Queues, Follow-Up, Overpayments, and the Metrics That Run a Business Office
- Chapter 32 — Patient Financial Responsibility: Estimates, Statements, Price Transparency, Collections, and Financial Assistance
8
Part VII: Facility, Specialty, and Risk-Adjusted Coding
5 chapters- Part VII — Facility, Specialty, and Risk-Adjusted Coding
- Chapter 33: Inpatient Facility Coding: MS-DRGs, Present on Admission, and the Hospital Revenue Cycle
- Chapter 34: Outpatient Facility Coding: APCs, OPPS, Status Indicators, and the Ambulatory Surgery Center
- Chapter 35: Specialty Coding: Cardiology, Orthopedics, OB/GYN, Pediatrics, Emergency Medicine, and Anesthesia
- Chapter 36: Coding for Value: HCC Risk Adjustment, Quality Measures, and Value-Based Reimbursement
9
Part VIII: Audit, Certification, and the Career
5 chapters- Part VIII — Audit, Certification, and the Career
- Chapter 37: Auditing and Compliance: Internal Audits, External Audits, and Protecting Your Organization
- Chapter 38: Clinical Documentation Integrity, Computer-Assisted Coding, and AI: The Technology Changing the Work
- Chapter 39: Certification: CPC, CCS, CCA, RHIT, RHIA — Which Path Is Right for You
- Chapter 40: The Revenue Cycle Career: From Entry-Level Coder to Revenue Cycle Director
10
Appendices
14 chapters- Appendix A — The Code Sets at a Glance: ICD-10-CM, CPT, and HCPCS Structure Reference
- Appendix B — Modifier Reference: What Each One Means and When to Use It
- Appendix C — The Encounter Workbook
- Appendix D — Claim Form Field Reference: CMS-1500 and UB-04, Box by Box
- Appendix E — Denial Codes and What to Do About Them
- Appendix F — Federal Law and Regulation Reference
- Appendix G — Documentation Requirements and Query Templates
- Appendix H — Worked Coding Scenarios
- Appendix I — The Certification Exam Study Guide
- Appendix J — Careers, Credentials, and Professional Development
- Answers to Selected Exercises
- Glossary
- Bibliography
- Index
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