Chapter 40 — Further Reading

The orientation for this chapter's sources. Chapter 40 has two halves and they need two different kinds of reading.

The capstone half (§40.1–§40.3) needs almost no outside source at all, and that is deliberate. Its four inputs came from earlier chapters of this book, and the arithmetic is division. What it needs instead is your own numbers, which live in your practice's payroll records and your own denial log, not in a publication. The reading below that touches it is about the frameworks — cost to collect, denial measurement, corrective action — and every one of them will tell you the same thing this chapter does: build the number from your own data.

The career half (§40.4–§40.11) has a hard rule attached. Everything about credentials, exams, continuing education, and experience requirements is set by the credentialing organizations and revised. Everything about compensation is a moving, self-selected, geographically enormous distribution. This book publishes no salary figure, no job-growth statistic, and no survey result, and you should distrust any you encounter without a date, a geography, a setting, and a definition attached. The sources below tell you where to look; they do not tell you what you will find.

And the standing rule of the whole book applies hardest in the last chapter. ICD-10-CM changes every October 1. CPT changes every January 1. HCPCS Level II and the National Correct Coding Initiative edits change quarterly. Fee schedules, relative value units, diagnosis-related group weights, and ambulatory payment classification rates change annually by rule. Coverage determinations change continuously. Read at the source, note the date you read it, and code from the current year's book or encoder — never from a textbook, including this one.

Tier 1 — Verified canonical

For the capstone and its arithmetic

• Your own payroll and overhead records. The most important source for §40.2, and it is not a publication. The fully loaded cost of a business-office hour — wage, payroll taxes, benefits, workstation, software, space, supervision — takes about an hour with a bookkeeper, and Chapter 31 §31.7 says so for exactly this reason. Every number in §40.3 is downstream of this one, and it is the only input you can obtain with certainty.

• Your own denial log. The second irreplaceable source. Chapter 29 §29.7 specifies the fields; the two most often omitted are root cause category and outcome, and they are the two that make the log worth keeping. Sorting it by the allowed amount on the denied line is the single analytical move §40.3 asks of you, and it requires no software you do not already own.

• The Medicare Claims Processing Manual (CMS Pub. 100-04) and the Medicare Program Integrity Manual (CMS Pub. 100-08). Free, searchable, and the authority behind a great deal of what this book has taught about claims, review, and appeals. §40.10's reading habit works well against a single chapter of either.

• The National Correct Coding Initiative Policy Manual, published by CMS and updated on a schedule. The document behind the modifier 25 argument that won Account 10-4471's appeal, and the best twenty minutes a month a coder can spend.

• The ICD-10-CM Official Guidelines for Coding and Reporting. Free, republished annually, and the first item on §40.10's calendar. Read the changes, not a summary of the changes.

For the career half

• The credentialing organizations' own current publications — AAPC and the American Health Information Management Association (AHIMA). They are the authority on their own credentials in a way no third party can be, which Chapter 39's further reading argues at length. For §40.4 and §40.9 the documents that matter are the current experience and apprentice-removal requirements, the specialty credential eligibility conditions, and the continuing-education requirements. Every one is revised. Read the current page and note the date.

• The Bureau of Labor Statistics occupational profile covering medical records and health information work. A genuine federal statistical product, published on a schedule, with state and metropolitan tables — and the tables are the point. A national median in this field can be off by a large multiple against a specific job in a specific county, which is exactly what §40.4 warns about. Read the methodology note too: what the occupation includes and excludes changes what the number means.

• The credentialing organizations' member salary surveys. Genuinely useful and structurally limited in a way worth naming: they are self-reported and member-only, which makes them a survey of a self-selected population rather than of the occupation. Read them alongside the Bureau of Labor Statistics profile rather than instead of it, and read neither instead of thirty local postings.

• HIPAA's Privacy and Security Rules, and the HITECH Act, for §40.8. The business associate relationship, the direct obligations that reach subcontractors, and the minimum necessary standard are the framework behind every outsourced and offshore arrangement. The Office for Civil Rights publishes plain-language guidance alongside the rules.

• The False Claims Act (31 U.S.C. §§ 3729–3733) and the Affordable Care Act sixty-day overpayment provision, for the sentence in §40.8 that does the most work: a function can be delegated; the attestation cannot.

For the two case studies

• The HHS final rules adopting ICD-10-CM and ICD-10-PCS and setting — then moving — the compliance date, and the Protecting Access to Medicare Act of 2014, whose ICD-10 provision is the statutory delay Case Study 1 turns on. Both are in the public record and both are short enough to read.

• The CMS/AMA joint guidance of July 2015 on the twelve-month flexibility for Medicare Part B claims regarding code specificity within the correct family. Frequently mischaracterized at the time as a further delay; reading it settles what it actually said.

• The CY2019 and CY2020 Medicare Physician Fee Schedule final rules, for Case Study 2. Read them as a pair and in order: the first finalizes the blended office-visit payment rate effective CY2021, the second declines to implement it and aligns instead with the revised code set. This is the clearest short lesson available anywhere on what "final rule" does and does not mean.

• The AMA's published office/outpatient E/M guidelines effective January 1, 2021, and the CPT code book that carries them. The primary document for the change that retired history and examination as level-determining elements for that family.

Tier 2 — Attributed, specifics unverified

Real practice, real benchmarks, real figures whose current values this book does not pin down. Ranges only; verify before quoting.

• HFMA's MAP Keys and comparable standardized revenue-cycle metric definitions. The value here is the definitions, not the benchmark values — Chapter 29 §29.7's denominator problem is precisely why a shared definition is worth more than a shared number. Cost to collect, days in accounts receivable, denial rate, and first-pass resolution rate all mean several different things until somebody writes down which one.

• Published denial-rate and overturn-rate benchmarks from industry surveys and clearinghouse data. Read them, and read them the way Chapter 29 §29.7 insists: a published rate was computed under somebody else's three choices about lines-or-claims, zero-pay-or-any-adjustment, and adjudicated-or-submitted. Comparing your number to it is a comparison of definitions at least as much as of performance.

• Cost-to-collect benchmarks for physician practices, commonly discussed in the low single digits as a percent of collections. Varies with specialty, payer mix, and — decisively — what gets counted. Verify current figures and the definition together or not at all.

• Coder productivity benchmarks, published by professional associations, consultancies, and vendors. Useful as a sanity check and dangerous as a standard, for the reason §40.6 gives: almost none of them state whether the rate is over chart time or over a working day, and the difference is the entire second half of the job.

• Remote, contract, and outsourced arrangement prevalence. Widely discussed, genuinely common, and poorly measured. Characterize; do not quote a share.

• Continuing education requirements, credential maintenance fees, and specialty credential eligibility. Tier 2 at best from any source other than the organization itself, and revised. Chapter 39 §39.11 owns this material and says the same thing.

Tier 3 — Illustrative / constructed

Everything in this chapter's worked arithmetic. Named here so no reader mistakes any of it for a benchmark.

• Account 10-4471, Northgate Family Medicine, and Northfield Mutual Health Plan. Constructed throughout the book. The five-physician practice, its ~19,000 encounters a year, its one coder and one biller, and every dollar on the account.

• The four capstone inputs and everything derived from them. 58 minutes across three touches; \$36.00 per hour fully loaded; \$128.40 allowed on the denied line; a 68% overturn rate from 57 of 84 appeals decided. And therefore \$34.80, \$93.60, and \$51.18 — all constructed, all arithmetically exact given the inputs, and none of them a benchmark.

• ⚠️ Figure 40.2's distribution and the 41%. The sort of Northgate's 267 denied lines by allowed amount is constructed for this chapter. The method generalizes. The number does not. A reader should leave able to compute their own break-even and their own share below it — never quoting 41% at a manager, and never treating it as an industry figure, because it is a property of one teaching log.

• The \$102.00 fix, the coding-day queue model, and every minute figure in §40.6. Constructed teaching figures built to show a structure. Your tasks, your systems, and your mix will differ enormously.

• The two 📞 On the Phone conversations. Constructed, and written to be close to real ones. No named person appears anywhere in this book; the participants are roles.

The three things worth reading if you read nothing else

1. Your own payroll's loaded hourly cost, and your own denial log sorted by value. Not a publication, and the only two documents that make §40.3 yours instead of Northgate's.
2. The ICD-10-CM Official Guidelines, this year's. Free, annual, and the closest thing this profession has to a constitution. Twenty minutes a month against it is §40.10's whole prescription.
3. The current requirements page for your own credential, read at the source and dated. Because everything anyone tells you about it — including this book — is a description that ages, and the organization is the authority.