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HSA-6197 Health Information System and Electronic Health
Records Week 4
Critical Reflection Paper: Chapters 7 & 8
·
Objective: To judgmentally reflect your understanding of the
readings and your skill to apply them to your Health care
Setting.
ASSIGNMENT GUIDELINES (10%):
Students will censoriously scrutinize the readings from Chapter
7and 8 in your textbook. This project is planned to help your
assessment, analysis, and apply the readings to your Health
Care Organization as well as become the foundation for all your
outstanding jobs.
You need to read the chapters assigned for week 4 and develop
a 2-3-page paper reproducing your understanding and ability to
apply the readings to your Health Care Organization. Each
paper must be typewritten with 12-point font and double-spaced
with standard margins. Follow APA style 7th edition format
when referring to the selected articles and include a reference
page.
EACH PAPER SHOULD INCLUDE THE FOLLOWING:

1. Introduction (25%) Deliver a short-lived synopsis of the
meaning (not a description) of each Chapter and articles you
read, in your own words.
2. Your Critique (50%)
What is your reaction to the content of the articles?
What did you learn about Medical Coding and the Purpose of
ICD-9-CM?
What did you learn about PPO, HMO and POS Health Plans?
Did these Chapter and articles change your thoughts about
Third-Party Payers? If so, how? If not, what remained the same?
3. Conclusion (15%)
Briefly summarize your thoughts & conclusion to your critique
of the articles and Chapter you read. How did these articles and
Chapters impact your thoughts on the purpose of an electronic
encounter form in an EHR.
Evaluation will be based on how clearly you respond to the
above, in particular:
a) The clarity with which you critique the chapters.
b) The depth, scope, and organization of your paper; and,
c) Your conclusions, including a description of the impact of
these articles and Chapters on any Health Care Setting.
ASSIGNMENT RUBRICS
Assignments Guidelines
10 Points
10%
Introduction
25 Points
25%
Your Critique
50 Points
50%
Conclusion
15 Points
15%
Total

100 points
100%
HSA-6197 Health Information System And Electronic Health
Record
Final Project
Final Project: Implementation Assessment of Electronic Health
Record.
Objective:
For this assignment, you will create the assessment to
implement the new HER in a Health care setting. The
assessment phase is foundational to all other EHR
implementation steps, and involves determining if the practice
is ready to make the change from paper records to
electronic (EHRs), or to upgrade their current system to a new
certified version. You will be encourage to choose a Community
Health Center or a Doctor’s Office. The Assessment is designed
because our world has been radically transformed by digital
technology – smart phones, tablets, and web-enabled devices
have transformed our daily lives and the way we communicate.
Medicine is an information-rich enterprise. A greater and more
seamless flow of information within a digital health care
infrastructure, created by electronic health records (EHRs),
encompasses and leverages digital progress and can transform
the way care is delivered and compensated. With EHRs,
information is available whenever and wherever it is needed.
The Health Information Technology for Economic and Clinical
Health (HITECH) Act, a component of the American Recovery

and Reinvestment Act of 2009, represents the Nation’s first
substantial commitment of Federal resources to support the
widespread adoption of EHRs. As of August 2012, 54 percent of
the Medicare- and Medicaid-eligible professionals had
registered for the meaningful use incentive program.
The paper will be 8-10 pages long. More information and due
date will provide in the assignments link.
The assessment should look at the current state of the practice:
· Are administrative processes organized, efficient, and well
documented?
· Are clinical workflows efficient, clearly mapped out, and
understood by all staff?
· Are data collection and reporting processes well established
and documented?
· Are staff members computer literate and comfortable with
information technology?
· Does the practice have access to high-speed internet
connectivity?
· Does the practice have access to the financial capital required
to purchase new or additional hardware?
· Are there clinical priorities or needs that should be addressed?
· Does the practice have specialty specific requirements?
Through the Regional Extension Centers (RECs), we’ve learned
that these questions and assessment tools provide a good
understanding of the current state of the practice and can help
identify key goals for improvement. Often, these goals relate to
patient quality, patient satisfaction, practice productivity and
efficiency, improved quality of work environment, and most
important to the overall goal – improved health care.

1. Introduction (25%) Offer an abstract that provide a brief
outlook of the proposal and explaining in your own words what
is meant by a Electronic Health Record for a Health care
Facility.
2. Your Implementation Assessment of Electronic Health
Record. Plan (50%)
a. Presentation Page:
PROJECT NAME
ORGANIZATION NAME
BUSINESS ADDRESS
CITY, ST, ZIP
TELEPHONE NUMBER
FACSIMILE NUMBER
WEBSITE ADDRESS
EMAIL ADDRESS
b. Envision the Future
The next EHR implementation step is to envision the future
state of the practice. What would the practice leadership like to
see different in the future? More specifically:
· What will be different for the patients?
· What will be different for the providers?
· What will be different for the staff?c.Set Goals
Goals and needs should be documented to help guide decision-
making throughout the implementation process. And they may
need to be re-assessed throughout the EHR implementation
steps to ensure a smooth transition for the practice and all staff.
We recommend that you set goals in areas that are important
and meaningful to your practice. These may be clinical goals,
revenue goals, or goals around work environment. Goals in all
three areas will help assure balanced processes after the
implementation. Goals that are important to you will help you
and your staff through the change process. We recommend you
follow the “SMART” goals process. This process includes
setting objectives and goals that meet the following criteria:

· Specific – Achieving the goal would make a difference for our
patients and our practice
· Measureable – We can quantify the current level and the target
goal
· Attainable – Although the goal may be a stretch, we can
achieve it
· Relevant – This is worth the effort
· Time bound – There are deadlines and opportunities to
celebrate success!
These goals become the guide posts for an EHR implementation
project, and achieving these goals will motivate providers and
practice staff to make necessary changes and attain new skills.d.
Plan Your ApproachClarify and Prioritize
Building an EHR implementation plan becomes critical for
identifying the right tasks to perform, the order of those tasks,
and clear communication of tasks to the entire team involved
with the change process. One effective first step in the planning
process is for the team to segment tasks into three categories:
· What new work tasks/process are we going to start doing?
· What work tasks/process are we going to stop doing?
· What work tasks/process are we going to sustain?
The start/stop/sustain exercise helps clarify what the new work
environment will be like after the change and help the team
prioritize tasks in the overall EHR implementation plan.Steps in
the Planning Phase
Here are some tactical steps that typically occur during the EHR
implementation planning phase. You may collaborate and use
tools provided by your Regional Extension Center (REC), IT
vendor, and/or EHR vendor (if you already have an existing
EHR product) to complete these activities.
1. Analyze and map out the practice’s current workflow and
processes of how the practice currently gets work done (the
current state).
2. Map out how EHRs will enable desired workflows and
processes, creating new workflow patterns to improve
inefficiency or duplicative processes (the future state).

3. Create a contingency plan – or back-up plan – to combat
issues that may arise throughout the implementation process.
4. Create a project plan for transitioning from paper to EHRs,
and appoint someone to manage the project plan.
5. Establish a chart abstraction plan, a means to convert or
transform, information from paper charts to electronic charts.
Identify specific data elements that will need to be entered into
the new EHR and if there are items that will be scanned.
6. Understand what data elements may be migrated from your
old system to your new one, such as patient demographics or
provider schedule information. Sometimes, being selective with
which data or how much data you want to migrate can influence
the ease of transition.
7. Identify concerns and obstacles regarding privacy and
security and create a plan to address them. It is essential to
emphasize the importance of privacy and security when
transitioning to EHRs.
e. Achieve Meaningful Use
The Medicare and Medicaid EHR Incentive Programs provide a
financial incentive for achieving "meaningful use", which is the
use of certified EHR technology to achieve health and
efficiency goals. This section provides an overview of the Stage
1 and Stage 2 EHR meaningful use core and menu objectives for
eligible professionals (EPs) as outlined by CMS – which are
intended to set a baseline for electronic data capture and
information sharing.
The meaningful use objectives are grouped into five patient-
driven domains that relate to health outcomes policy priorities.
As depicted in the dashboards below, each core and menu

objective is aligned to one of the following domains:
· Improve Quality, Safety, Efficiency
· Engage Patients & Families
· Improve Care Coordination
· Improve Public and Population Health
· Ensure Privacy and Security for Personal Health Information
3. Conclusion ( 15%)
Briefly recapitulate your thoughts & conclusion to Your
Implementation Assessment of Electronic Health Record. Plan.
How did this plan impact your thoughts on Health Care
Administrator and Health Information System?
a) The clarity with which you associate, relates, stablish and
apply your knowledge to generate theImplementation
Assessment of Electronic Health Record Plan.
b) The Complexity, depth, scope, Profundity and organization
of your paper; and,
the Electronic Health Record on any Health Care Setting.
HSA-6197 Health Information System and Electronic Health
Records Week 6
Financial Report in Medisoft Network Professional (MNP):
Chapters 11 & 12
Objective: To critically reflect your understanding of the
readings and your ability to apply them to your Health care
Setting.
Financial Report in Medisoft Network Professional (MNP). For
this assignment, you will critically evaluate, create and
generated a Medisoft Report and apply a specific financial

report available in MNP within a Health Care Setting, for a
specific patient, describe and select data to be include in a MNP
report, create a patient ledger report, and create a standard
patient list report. You are invigorated to choose a specific
Health Care Facility as a reference to do this assignment
You need to read the article (in the additional weekly reading
resources localize in the Syllabus and also in the Lectures link)
assigned for week 6 and develop a 4-6-page paper reflecting
your understanding and ability to apply the readings to your
Health Care Setting. Each paper must be typewritten with 12-
point font and double-spaced with standard margins. Follow
APA 7th edition format when referring to the selected articles
and include a reference page.
1. Introduction (25%) Provide a short-lived outline of the three
types of financial reports available in MNP (not a description)
of each Chapter and articles you read, in your own words.
I’m
2. Medisoft Financial Report (50%): Create a Medisoft Report
with the following information:
Select data to be include in a MNP.
Create three day Sheets: Patient Day Sheet, Procedures Day
Sheet, and Payment Day Sheet.
Analysis Report
3. Conclusion (15%)
Briefly summarize your thoughts & conclusion to your critique
of the articles and Chapter you read. How did these articles and
Chapters impact your thoughts on Financial and clinical reports.
a) The clarity with which you critique the articles;
b) The depth, scope, and organization of your paper; and,
these articles and Chapters on any Health Care Setting.

ASSIGNMENT RUBRICS
10 Points
10%
Introduction
25 Points
25%
Your Critique
50 Points
50%
Conclusion
15 Points
15%
Total
100 points
100%
HAS-6197 Health Information System and Electronic Health
Record: Week 5
Administrative and Structural Analysis of an Electronic Health
Claim Management: Chapters 9 &10
Objective: In this assignment you are request to you will
describe, analyze and apply process of creating claims, locating
specific claim, methods used to submit electronic claims, and
the claim determination process used by health plans.
Students will judgmentally evaluate the readings from Chapter 9
and 10 on your textbook and from the article assigned for week

5. The Purpose of this Administrative and Structural Analysis of
an Electronic Health Claim Management is to describes the
potential benefits of EHRs that include clinical outcomes (eg,
improved quality, reduced medical errors), organizational
outcomes (eg, financial and operational benefits), and societal
outcomes (eg, improved ability to conduct research, improved
population health, reduced costs). Despite these benefits,
studies in the literature highlight drawbacks associated with
EHRs, which include the high upfront acquisition costs, ongoing
maintenance costs, and disruptions to workflows that contribute
to temporary losses in productivity that are the result of
learning a new system. Moreover, EHRs are associated with
potential perceived privacy concerns among patients, which are
further addressed legislatively in the HITECH Act. Overall,
experts and policymakers believe that significant benefits to
patients and society can be realized when EHRs are widely
adopted and used in a “meaningful” way.
You need to develop a 4-5-page paper long including title page
and references page reproducing your understanding and
capability to relate the readings to claim management. Each
paper must be typewritten with 12-point font and double-spaced
with standard margins. Follow APA style 7th format when
referring to the selected articles and include a reference page.
1. Introduction (25%) Provide a brief synopsis of the meaning
(not a description) of each Chapter and articles you read, in
your own words.
2. Your Strategies (50%)
a. Briefly compare the CMS-1500 paper claim and the 837
electronic.
b. Discussion the information contained in the claim
management dialog box
c. Analyze the method used to submit electronic claims.
d. Discuss the use of the PM/HER to monitor claims.
3. Conclusion (15%)

Briefly summarize your thoughts & conclusion to this
assignment and your appraisal of the Chapter you read. How
did these articles and Chapters impact your thoughts about
Claim Management? How this Administrative Analysis help you
in relation to Claim management in Medisoft.
a) The clarity with which you present and analyzed the
strategies;
b) The depth, scope, and organization of your Administrative
Analysis paper; and,
these articles and Chapters on any Healthcare Organization.
ASSIGNMENT RUBRICS
1 Points
10%
Introduction
2.5 Points
25%
Your Strategies
5 Points
50%
Conclusion
1.5 Points
15%
Total
10 points
100%

CHAPTER
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
McGraw-Hill
12
Financial and Clinical Reports
*
Learning Outcomes
When you finish this chapter, you will be able to:
12.1 List the three types of financial reports available in
Medisoft Network Professional (MNP).
12.2 Describe how to select data to be included in a MNP
report.
12.3 Compare patient, procedure, and payment day sheets.
12.4 Discuss the purpose of a practice analysis report.
12.5 Explain how to create a production by provider report.
12.6 List the steps for creating a patient ledger report.
12-2
*

Learning Outcomes (Continued)
12.7 Describe how to create a standard patient list report.
12.8 Describe the use of Medisoft Reports to create a report.
12.9 Explain how aging reports are used in a medical
practice.
12.10 Explain how to access MNP’s built-in custom reports.
12.11 Describe the process of editing reports in MNP’s
Report Designer.
12-3
*
12.12 List the reasons for using reports for tracking specific
clinical data.
12.13 Discuss the regulatory obligations for the retention of
patient medical records.
12-4
*
Key Termsaging reportday sheetinsurance aging reportpatient
aging reportpatient day sheetpatient ledgerpatient
registrypayment day sheetperformance measurespractice

analysis report
12-5procedure day sheetproduction by provider
reportretentionselection boxes
Teaching Notes: If possible, pass around samples of each
report/sheet in the key terms section and see if students can
classify the form correctly. If forms are not available, prepare a
matching activity where students match the forms and reports to
what they represent.
*
12.1 Types of Reports in Medisoft
Network Professional
12-6
MNP offers several options for creating reports on its Reports
menu, including:Standard reportsMedisoft Reports…Design
Custom Reports and Bills…
Learning Outcome: 12.1 List the three types of financial reports
available in Medisoft Network Professional (MNP).
Teaching Notes: Showcase Figure 12.1 in the textbook and take
some time to walk through each type of report listed and the
category (Standard, Medisoft, Custom) under which each type
of report falls.
*

12.2 Selecting Data for a Report
12-7
To select data to be included in an MNP report:Once a selection
is made in the Print Report Where? Dialog box, click the Start
button; the Search dialog box is displayed.Selection boxes—
fields within the Search dialog box that are used to select the
data that will be included in a reportUse the drop-down list or
Lookup button for the selection boxes to input data.After the
selections/inputs have been made, click the OK button to
generate the report.
Learning Outcome: 12.2 Describe how to select data to be
included in an MNP report.
Teaching Notes: Explain that the selection boxes make report
creation easy and quick. Reference some of the selection boxes
within the Search feature that you might use – date, provider,
insurance carrier, etc.
*
12.3 Day Sheets
12-8Day sheet—report that provides information on practice
activities for a twenty-four hour periodPatient day sheet—
summary of patient activity on a given dayProcedure day
sheet—report that lists all the procedures performed on a
particular day, in numerical orderPayment day sheet—report
that lists all payments received on a particular day, organized
by provider
Learning Outcome: 12.3 Compare patient, procedure, and
payment day sheets.

Teaching Notes: Have students brainstorm what types of
situations would warrant printing a patient, procedure, or
payment day sheet. Use responses as a springboard for
discussion.
Have students complete Exercise 12.1.
*
12.4 Analysis Reports
12-9Practice analysis report—report that analyzes the revenue
of a practice for a specified period of timeUsually used to report
on a month or a yearCan be used to generate medical practice
financial statementsCan also be used for profit analysis
Learning Outcome: 12.4 Discuss the purpose of a practice
analysis report.
Teaching Notes: Note that while practice analysis reports are
the most common financial reports used in a practice, Medisoft
Network Professional also prints reports that deal with, among
other things, patients with outstanding co-payments, the average
payment received for various procedure codes, and referring
providers.
Use Figure 12.16 in the text to show all of the available
analysis reports. Ask students why the practice analysis is the
most common. See if they can list a benefit for each type of
report. This could be a group discussion or an individual
assignment.

*
12.5 Production Reports
12-10Production by provider report—report that lists incoming
revenue information for each provider in the practiceTo create a
production by provider report in MNP:Click Production Reports
from the Reports menu, then Production by Provider; the Print
Report Where? Dialog box appears.Select the destination and
click Start.Make the appropriate selections in the selection
boxes.Click OK; the report will be sent to its destination.
Learning Outcome: 12.5 Explain how to create a production by
provider report.
Teaching Notes: There are a number of other “production by…”
reports available in MNP. (Figure 12.19 in the text shows all
available reports.) Encourage students to think about the uses
of different reports.
*
12.6 Patient Ledger Reports
12-11Patient ledger—report that lists the financial activity in
each patient’s accountTo create a patient ledger report in
MNP:Click Patient Ledger on the Reports menu; the Print
Report Where? Dialog box is displayed.Select preview, print, or
export; the Search dialog box is displayed.Make the appropriate
selections.Click the OK button; the report is displayed.

Learning Outcome: 12.6 List the steps for creating a patient
ledger report.
Teaching Notes: Note that the patient ledger report is another
standard report in MNP, useful especially when there is a
question about a patient’s account. Use this opportunity to
again stress how important proper documentation and record
keeping are!
*
12.7 Standard Patient Lists
12-12To create a standard patient list report in MNP:Click
Standard Patient Lists from the Reports menu.Select either
Patient by Diagnosis or Patient by Insurance Carrier.Make a
selection in the Print Report Where? Dialog box.Make the
appropriate data input selections and click the OK button; the
report will be displayed.
Learning Outcome: 12.7 Describe how to create a standard
patient list report.
Teaching Notes: Explain that there are two types of standard
patient lists: patient by insurance carrier and patient by
diagnosis. Ask students why it might be helpful to be able to
sort patients by diagnosis.
*

12.8 Navigating in Medisoft Reports
12-13The Medisoft Reports feature offers the user access to
over a hundred reports.Medisoft Reports contains these features
that help in creating a report:The Medisoft Reports menusThe
Medisoft Reports toolbarThe Medisoft Reports Find Report box
and the Find Now buttonThe Medisoft Reports help feature
Learning Outcome: 12.8 Describe the use of Medisoft Reports
to create a report.
Teaching Notes: Note that the Medisoft Reports feature is a new
addition to MNP; what benefits does it offer (especially since
many of the reports can be accessed through other report
functions)?
Point out Figure 12.25 in the textbook, which shows the
Medisoft Reports menu. Ask students to skim through it and
discuss what they notice about it and its organization.
*
12.9 Aging Reports
12-14Aging reports—report that lists the amount of money
owed to the practice, organized by the amount of time the
money has been owedUsed by medical practices to determine
which accounts require follow-up to collect past-due
balancesPatient aging report—report that lists a patient’s
balance by age, date and amount of the last payment, and
telephone numberInsurance aging report—report that lists how

long a payer has taken to respond to insurance claims
Learning Outcome: 12.9 Explain how aging reports are used in a
medical practice.
Teaching Notes: Discuss the importance of aging reports –
timely and proper payment/reimbursement is critical for a
practice and is one of the areas that needs to be monitored most
closely.
*
12.10 Custom Reports
12-15MNP has a number of built-in custom reportsTo access
MNP’s built-in custom reports:Click the Custom Report List
option on the Reports menu; the Open Report dialog box is
displayed.Make the appropriate selections in the series of data
input dialog boxes.Make the appropriate selection in the
Preview Report window and click OK; the report will be
displayed.When a new custom report is created, it is added to
the list of custom reports displayed on the screen.
Learning Outcome: 12.10 Explain how to access MNP’s built-in
custom reports.
Teaching Notes: List some of the custom reports available:
patient walkout receipts, EDI receivers, referring providers, etc.
Figure 12.34 in the textbook showcases the Open Report dialog
box, which shows all possible custom reports…..notice the

“Birthday Card” option.
Have students complete Exercises 12.7 and 12.8.
*
12.11 Using Report Designer
12-16MNP’s Report Designer allows the user to modify existing
reports or create new reports.To edit reports using MNP’s
Report Designer:Click Design Custom Reports and Bills on the
Reports menu; the Report Designer will be displayed.Click
Open Report on the File menu to select a report.Double click in
the list to make edits.Click the OK button to make the
changes.Click Preview Report on the File menu to save the file
as a new report; key in the new report name.Click the OK
button, make the appropriate selections, and click the OK button
again; the report is shown.
Learning Outcome: 12.11 Describe the process of editing
reports in MNP’s Report Designer.
Teaching Notes: Explain to students that each practice is able
to create its own custom reports using this feature; new reports
can be saved to the Custom Reports list. While the details of
actual report creation are beyond the scope of this text,
referencing it for students can be helpful.
*

12.12 Preparing Clinical Reports
12-17MNP’s reports can be used to capture the required items
for performance measure reporting and for meaningful
use.Performance measure—processes, experience, and/or
outcomes of patient care, observations, or treatment that relate
to one or more quality aims for health care, such as effective,
safe, efficient, patient-centered, equitable, and timely care
Learning Outcome: 12.12 List the reasons for using reports for
tracking specific clinical data.
Teaching Notes: Ask students how MNP’s reports can be used
to prove compliance with various HIPAA, HITECH, and
government incentive acts.
Ask students what “meaningful use” means. Discuss
meaningful use’s implications for the healthcare field.
Provide specific examples of performance measures:
therapeutic interventions such as physical therapy, preventative
measures such as mammograms, and other interventions such as
counseling.
*
12.12 Preparing Clinical Reports (Continued)
12-18Patient registry—method of reporting clinical data to
payers using an online service rather than claims-based
reporting
Learning Outcome: 12.12 List the reasons for using reports for
tracking specific clinical data.

Teaching Notes: Explain that if a practice chooses not to use a
patient registry, it will most likely use a clearinghouse to report
pertinent information.
*
12.13 Record Retention
12-19Retention—preservation of information on patients’
medical conditions for continuity of careRetention is
performed:According to the practice’s retention scheduleTo
protect both the provider and the patientIn accordance with
federal business records retention requirements, and any state
requirements that applyUnder HIPAA, covered entities must
keep records of HIPAA compliance for six years.
Learning Outcome: 12.13 Discuss the regulatory obligations for
the retention of patient medical records.
Teaching Notes: After discussing record retention, discuss with
students what must/should happen when it is time to dispose of
records. Ask them how the advent of electronic records
influences the disposal of records and information. Is it better
or worse than before? Why?
*
CHAPTER
8

Third-Party Payers
*
McGraw-Hill
Learning Outcomes
8.1 Compare the major features of PPO, HMO, and POS
health plans.
8.2 Identify the two parts of CDHPs.
8.3 Discuss the organization and regulation of employer-
sponsored group health plans and self-insured plans.
8.4 Explain the purpose of Medicare Parts A, B, C, and D.
8.5 Describe the fee structures that are used to set
charges.
8-2
*
McGraw-Hill
8.6 Identify the three methods most payers use to pay
physicians.
8.7 Maintain insurance carrier information in the PM/EHR.
8-3

*
McGraw-Hill
Key Termsallowed chargebalance billingBlue Cross and Blue
Shield Association (BCBS)capitation (cap) rateCivilian Health
and Medical Program of the Department of Veterans Affairs
(CHAMPVA)consumer-driven (directed) health plan (CDHP)
8-4disability compensation programsdiscounted fee-for-
servicedual-eligibleEmployment Retirement Income Security
Act of 1974 (ERISA)Federal Employees Health Benefits
(FEHB)fee scheduleflexible savings account (FSA)
Teaching Notes: There are a lot of key terms, so here are some
options to help present them:
Put students into small groups and assign each group a set of
terms to define and learn. Then have each group teach their set
of terms to the rest of the class.
Assign each student a set number of terms to define as a
homework assignment and then discuss the terms together
during class.
Ask students whether any of the key terms are familiar to them
already; use their responses to launch a discussion of the rest of
the terms.
*
McGraw-Hill

Key Terms (Continued)group health plan (GHP)health
maintenance organization (HMO)health reimbursement account
(HRA)health savings account (HSA)high-deductible health plan
(HDHP)individual health plan (IHP)Medicaid
8-5MedicareMedicare Part A, Hospital Insurance (HI)Medicare
Part B, Supplementary Medical Insurance (SMI)Medicare Part
C, Medicare AdvantageMedicare Part DMedicare Physician Fee
Schedule (MPFS)Medigap
Teaching Notes: See notes on Slide 4.
*
McGraw-Hill
Key Terms (Continued)Medi-Medi beneficiaryOriginal
Medicare Planpoint-of-service (POS) planpreferred provider
organization (PPO)primary care physician (PCP)relative value
scale (RVS)resource-based relative value scale (RBRVS)
8-6self-insured health plansthird-party payerTRICAREusual,
customary, and reasonable (UCR)usual feesworkers’
compensation insurancewrite off
*
McGraw-Hill

8.1 Types of Health Plans
8-7Third-party payer—private or government organization that
insures or pays for health care on behalf of
beneficiariesPreferred provider organization (PPO)—managed
care network of health care providers who agree to perform
services for plan members at discounted ratesThe policyholder
pays an annual premium and a yearly deductible.A PPO may
offer either a low deductible with a higher premium or a high
deductible with a lower premium.
Learning Outcome: 8.1 Compare the major features of PPO,
HMO, and POS health plans.
Teaching Notes: Slides 8-7 through 8-10 list the various types
of health plans. Consider the following options for covering
and discussing the plans:
Draw a table on the board that lists the insurance types along
the left side and various pieces of information (annual premium,
needs referrals, copayments, etc.) along the top. Use this table
to create a compare-contrast grid by checking the pieces of
informational that fit each insurance type.
Provide descriptions of each type of insurance and the names of
each type; see if students can match each type to its description.
Put students into groups and have each group research one type
of insurance. Then have the group “teach” the type to the class.
Cite the advantages and disadvantages of each type of plan, and
note what might cause a patient to choose one type over
another.
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McGraw-Hill
8.1 Types of Health Plans (Continued)

8-8PPO features (continued):Members typically pay a
copayment at the time of service, and coinsurance may also be
charged.Patients may see out-of-network doctors without a
referral or preauthorization; the amount they have to pay will be
higher.Health maintenance organization (HMO)—managed care
system in which providers offer health care to members for
fixed periodic paymentsThis type of health plan has the most
stringent guidelines and the narrowest choice of providers.
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McGraw-Hill
8-9HMO features (continued):A Primary care physician (PCP)
is a physician in a managed care organization who directs all
aspects of a patient’s care; members are assigned to a
PCP.Members must use their HMO’s network except in
emergencies or pay a penalty.HMOs are organized around one
of three business models: the staff model, the group or network
model, and the independent practice association model.
*

McGraw-Hill
8-10Point-of-service (POS) plan—managed care plan that
permits patients to receive medial services from nonnetwork
providersA POS plan is a hybrid of HMO and PPO
networks.Members may choose from a primary or secondary
network.This kind of plan charges annual premiums and
copayments for office visits.Indemnity or fee-for-service plans
require premium, deductible, and coinsurance payments.
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McGraw-Hill
8.2 Consumer-Driven Health Plans
8-11Consumer-driven (directed) health plan (CDHP)—medical
insurance that combines a high-deductible health plan with one
or more tax-preferred savings accounts that the patient
directsHigh-deductible health plan (HDHP)—health plan that
combines high deductible insurance and a funding option to pay
for patients’ out-of-pocket expenses up to the deductibleFirst
part of a CDHPAnnual deductible over $1,000
Learning Outcome: 8.2 Identify the two parts of CDHPs.

Teaching Notes: Explain the reasons for a high deductible;
discuss what happens when a patient reaches the deductible
limit.
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McGraw-Hill
8.2 Consumer-Driven Health Plans (Continued)
8-12The second part of a CDHP involves one of three types of
funding options:Health reimbursement account (HRA)—CDHP
funding option where an employer sets aside an annual amount
for health care costsHealth savings account (HSA)—CDHP
funding option under which funds are set aside to pay for
certain health care costsFlexible savings account (FSA)—CDHP
funding option that has employer and employee contributions
Learning Outcome: 8.2 Identify the two parts of CDHPs.
Teaching Notes: Have students debate which of these three
funding options is best; encourage them to look deeper than
“HRA is best because an employer pays it.”
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McGraw-Hill
8.3 Private Insurance Payers and Blue Cross and Blue Shield
8-13Group health plan (GHP)—plan of an employer or
employee organization to provide health care to employees,
former employees, and/or their familiesHuman resource
departments manage the health care benefits.Riders, or options,

are often offered for vision and dental services.During open
enrollment periods, employees choose the plans they prefer for
the coming benefit period.This kind of health plan must follow
federal and state laws.
Learning Outcome: 8.3 Discuss the organization and regulation
of employer-sponsored group health plans and self-insured
plans.
Teaching Notes: For slides 8-13 through 8-15, consider the
following options for covering and discussing the various types
of health plans. (NOTE: CHOSE AN OPTION THAT YOU
DID NOT PICK FOR SLIDES 8-7 through 8-10):
another.
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McGraw-Hill
(Continued)
8-14Federal Employees Health Benefits (FEHB)—health care
program that covers federal employeesSelf-insured health

plans—health insurance plans paid for directly by the
organization, which sets up a fund from which to payThese do
not pay premiums to insurance carriers or managed care
organizations.These set up their own provider networks or lease
the use of managed care organizations’ networks.
plans.
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McGraw-Hill
(Continued)
8-15Employee Retirement Income Security Act of 1974
(ERISA)—law providing incentives and protection for
companies with employee health and pension plansThe law
regulates self-insured health plans.Individual health plan
(IHP)—medical insurance plan purchased by an individualBlue
Cross and Blue Shield Association (BCBS)—licensing agency
of Blue Cross and Blue Shield plans
plans.

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8.4 Government-Sponsored Insurance
Programs, Workers’ Compensation,
and Disability Plans
8-16Medicare—federal health insurance program for people
sixty-five or older and some people with disabilitiesMedicare
Part A, Hospital Insurance (HI)—program that pays for
hospitalization, care in a skilled nursing facility, home health
care, and hospice careMedicare Part B, Supplementary Medical
Insurance (SMI)—program that pays for physician services,
outpatient hospital services, durable medical equipment, and
other services and supplies
Learning Outcome: 8.4 Explain the purpose of Medicare Parts
A, B, C, and D.
Teaching Notes: For slides 8-16 through 8-20, consider the
following options for covering and discussing the various types
of health plans. (NOTE: CHOSE AN OPTION THAT YOU
DID NOT PICK FOR SLIDES 8-7 through 8-10 and 8-13
through 8-15):

another.
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McGraw-Hill
and Disability Plans (Continued)
8-17Original Medicare Plan—Medicare fee-for-service
planMedigap—plan offered by a private insurance carrier to
supplement Medicare coverageMedicare Part C, Medicare
Advantage—managed care health plan under the Medicare
programMedicare Part D—Medicare prescription drug
reimbursement plans
A, B, C, and D.
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8-18Medicaid—federal and state assistance program that pays
for health care services for people who cannot afford themMedi-
Medi beneficiaries—people eligible for both Medicare and
MedicaidDual-eligible—Medicare-Medicaid
beneficiaryTRICARE—government health program serving
dependents of active-duty service members, military retirees
and their families, some former spouses, and survivors of
deceased military members
A, B, C, and D.
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8-19Civilian Health and Medical Program of the Department of
Veterans Affairs (CHAMPVA)—health care plan for families of
veterans with 100 percent service-related disabilities and the
surviving spouses and children of veterans who die from
service-related disabilities

A, B, C, and D.
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8-20Workers’ compensation insurance—state or federal plan
that covers medical care and other benefits for employees who
suffer accidental injury or become ill as a result of
employmentDisability compensation programs—programs that
provide partial reimbursement for lost income when a disability
prevents an individual from working
A, B, C, and D.
Teaching Notes: See notes on Slide 16. Also, when discussing
workers’ compensation insurance, do the following:
Explain that workers’ compensation includes five types of
payment:payment for medical treatments,payment for temporary
disability (to replace lost wages),permanent disability
payments,compensation for dependents of employees who are
fatally injured, andpayments in the form of vocational

rehabilitation.
Provide examples of current/recent workers’ compensation
suits; have students debate whether workers’ compensation
insurance is a help or hindrance. Ask them if they think
employees abuse the insurance, and have them explain their
reasoning. This could be done as a large or small group, or as
an individual assignment.
While this might be a touchy, potentially volatile subject, it is
one worth discussing. Tie responses to class lecture and the
text information.
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McGraw-Hill
8.5 Setting Fees
8-21Fee schedule—document that specifies the amount the
provider bills for servicesUsual fees—normal fees charged by a
providerMost payers use one of three methods to set the fees
that their plan will pay physicians: Usual, customary, and
reasonable (UCR)—fees set by comparing usual fees, customary
fees, and reasonable feesRelative value scale (RVS)—system of
assigning unit values to medical services based on their required
skill and timeResource-based relative value scale (RBRVS)—
relative value scale for establishing Medicare charges
Learning Outcome: 8.5 Describe the fee structures that are used
to set charges.
Teaching Notes: Explain that billers are the ones that
commonly hear questions from patients about fees; it is
important for them to know the ins and outs of the payment
plans.

Important: Most practices set their fees slightly above those
paid by the highest reimbursing plan in which they participate.
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McGraw-Hill
8.5 Setting Fees (Continued)
8-22Medicare Physician Fee Schedule (MPFS)—RBRVS-based
allowed fees that are the basis for Medicare reimbursements
Learning Outcome: 8.5 Describe the fee structures that are used
to set charges.
Teaching Notes: Ask students which of the three methods for
determining payer fees seems to be the most fair? Most logical?
Why?
Explain that there are three parts to an RBRVS fee, which are
updated every year:Nationally uniform relative value
unitGeographic adjustment factorNationally uniform conversion
factor
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McGraw-Hill
8.6 Third-Party Payment Methods
8-23Payers use one of three main methods of paying
providers:Allowed chargesContracted fee
schedulesCapitationAllowed charge—maximum charge a plan
pays for a service or procedureBalance billing—collecting the

difference between a provider’s usual fee and a payer’s lower
allowed charge
Learning Outcome: 8.6 Identify the three methods most payers
use to pay physicians.
Teaching Notes: Use Table 8.2 in the text to enhance
discussion; use the examples on pages 405-406 to illustrate the
abstract concepts for students.
*
McGraw-Hill
8.6 Third-Party Payment Methods (Continued)
8-24Write off—to deduct an amount from a patient’s
accountDiscounted fee-for-service—payment schedule for
services based on a reduced percentage of usual
chargesCapitation (cap) rate—periodic prepayment to a provider
for specified services to each plan member
Learning Outcome: 8.6 Identify the three methods most payers
use to pay physicians.
*
McGraw-Hill
8.7 Maintaining Insurance Information in the PM/EHR
8-25Setting up insurance carriers correctly in the PM/EHR is

essential to getting claims paid in a timely manner.To maintain
insurance carrier information in MCPR:Access the information
by selecting Insurance on the Lists menu.Select Carriers (to
enter, edit, or delete carriers) or Classes (for reporting) on the
submenu that appears.Select the Carriers option; the Insurance
Carrier List dialog box is displayed.
Learning Outcome: 8.7 Maintain insurance carrier information
in the PM/EHR.
Teaching Notes: Note that insurance carriers for a practice
must be set up in MCPR before they can be assigned to patients
and/or maintained.; the Insurance Carrier dialog box for each
carrier contains all pertinent information.
*
McGraw-Hill
8.7 Maintaining Insurance Information in the PM/EHR
(Continued)
8-26Maintaining carrier information (continued):Use the Edit,
New, and Delete buttons to change, create, and delete insurance
carriers.Use the Print Grid button to print the information.Close
the dialog box using the Close button.
Learning Outcome: 8.7 Maintain insurance carrier information
in the PM/EHR.
Teaching Notes: While walking through the steps required to
maintain insurance information, use the screenshots in the text
to aid understanding. Before assigning the exercises, ask
students if they have any outstanding questions on the process

of working with insurance information.
Have students complete Exercises 8.1-8.6.
*
CHAPTER
McGraw-Hill
11
Posting Payments and Creating Statements
*
Learning Outcomes
11.1 List the six steps for checking a remittance advice.
11.2 Describe the procedures for entering insurance
payments.
11.3 Explain how to apply insurance payments to charges.
11.4 Explain how to enter capitation payments.
11.5 Discuss the purpose of appeals and postpayment audits.
11.6 Compare standard patient statements and remainder
patient statements.
11-2

*
11.7 Explain the difference between once-a-month and cycle
billing.
11.8 Explain the procedure for processing a nonsufficient
funds payment.
11-3
*
Key Termsappealappellantautopostingcapitation paymentsclaim
adjustment group code (CAGC)claim adjustment reason code
(CARC)claimantclaim control numbercycle billing
11-4electronic funds transfer (EFT)electronic remittance advice
(ERA)explanation of benefits (EOB)nonsufficient funds (NSF)
checkonce-a-month billingoverpaymentpatient
statementpostpayment audit
Teaching Notes: There are a lot of key terms, but many of them
might already be familiar to your students. Give a pop quiz of
the terms to see how many students know. Grade the quiz in
class and use the results to focus your lecture on terms that
most or all students missed.
*

Key Terms (Continued)Recovery Audit Contractor
(RAC)remainder statementsremittance advice (RA)remittance
advice remark code (RARC)standard statementstakebackX12
835 Electronic Remittance Advice (835)
11-5
*
11.1 Working with the Remittance
Advice (RA)
11-6Remittance advice (RA)—document describing a payment
resulting from a claim adjudicationSix steps for checking a
remittance advice:
Check the patient’s name, claim control number, and date of
service against the claim.
Verify that all billed CPT codes are listed.
Check the payment for each CPT code against the expected
amount, which may be an allowed charge or a percentage of the
usual fee.
Analyze the payer’s adjustment codes to locate all unpaid,
downcoded, or denied claims for closer review.
Learning Outcome: 11.1 List the six steps for checking a
remittance advice.

Teaching Notes: Direct students’ attention to the sample RA,
Figure 11.1, in the text (or better yet, provide handouts of it for
quick reference during lecture). If possible, bring in sample
RAs and have students/groups analyze them using the 6 steps
for checking an RA.
*
Advice (RA) (Continued)
11-7Six steps for checking a remittance advice (continued):
Pay special attention to RAs for claims submitted with
modifiers.
Decide whether there are any items on the RA that need
clarification from the payer, and follow up as
necessary.Electronic remittance advice (ERA)—electronic
document that lists patients, dates of service, charges, and the
amount paid or denied by the insurance carrier
remittance advice.
Teaching Notes: See notes on Slide 6; discuss what additional
information/what benefits are available when using an
electronic remittance advice.
*

11-8X12 835 Electronic Remittance Advice (835)—electronic
transaction for payment explanationClaim control number —
unique number assigned to a claim by the senderAutoposting—
software feature enabling automatic entry of payments from a
remittance advice
remittance advice.
Teaching Notes: Here are some options for covering the key
terms on this slide and Slide 9; complete as many as desired or
as time allows:
List the terms on the board or on a worksheet. Ask students to
discuss where they have used or heard these terms before.
Provide sample insurance documents and ask students (in a
group activity, possibly) to identify the pieces of information
found in the document.
3.Put students in groups and have them research the history of
RAs, incorporating the terms from the slides; or, have them
choose one of the terms themselves and research its origins,
why it is used, etc. Students or groups can then report on their
findings, if desired.
*
11-9Claim adjustment group code (CAGC)—used on an
RA/EOB to indicate the general type of reason code for an
adjustmentAlso abbreviated GRPClaim adjustment reason code

(CARC)—used on an RA/EOB to explain why a payment does
not match the amount billedRemittance advice remark code
(RARC)—code that explain a payer’s payment decision
remittance advice.
*
11.2 Entering Insurance Payments
11-10Insurance payments are entered in the Deposit List dialog
box of MNPTo enter insurance payments:Select Enter
Deposits/Payments on the Activities menu, or click the Enter
Deposits and Apply Payments button; the Deposit List dialog
box opens.Complete the fields in the Deposit List dialog
box.Click the New button; the Deposit dialog box
appears.Complete the fields in the Deposit dialog box.Click the
Save button, and the deposit will be recorded.
Learning Outcome: 11.2 Describe the procedures for entering
insurance payments.
Teaching Notes: Ask students to speculate about why, if
patient payments are entered in the Transactions List dialog
box, insurance payments must be entered in the Deposit List
dialog box.
*

11.2 Entering Insurance Payments (Continued)
11-11Electronic funds transfer (EFT)—electronic routing of
funds between banksCapitation payments—payments made to
physicians on a regular basis for providing services to patients
in a managed care plan
Learning Outcome: 11.2 Describe the procedures for entering
insurance payments.
Teaching Notes: Contrast insurance payments and capitation
payments.
*
11.3 Applying Insurance Payments to Charges
11-12
To apply insurance payments to charges in MNP:Highlight the
payment in the Deposit List dialog box.Click the Apply button;
the Apply Payment/Adjustments to Charges dialog box
opens.Enter the payment in the middle section of this dialog
box.Click the Save Payments/Adjustments button to save an
entry; click OK when an information dialog box is
displayed.Repeat as needed, then use the Close button to exit.
Learning Outcome: 11.3 Explain how to apply insurance
payments to charges.
Teaching Notes: Use Figure 11.9 in the textbook to walk
through the dialog box students will use for this task; explain

and provide examples as needed.
Assign students Exercises 11.2, 11.3, and 11.4.
*
11.4 Entering Capitation Payments
11-13
To enter capitation payments in MNP:Open the Deposit List
dialog box, then the Deposit Window.Select capitation from the
Payor Type drop-down list in the Deposit window.Enter the
appropriate deposit information.Enter a second deposit as an
insurance payment with a zero amount and click Save; the
deposit appears in the Deposit List window.Use the List Only
Claims That Match dialog box to locate patients who have
claims covered by the capitation payment.
Learning Outcome: 11.4 Explain how to enter capitation
payments.
Teaching Notes: Explain that capitation payments are NOT
applied to individual patient accounts/charges; rather, a health
plan pays the practice a set fee to help cover insured patients.
Ask students if they think it makes sense that a practice receives
this payment regardless of the frequency of patient visits.
*
11.4 Entering Capitation Payments (Continued)
11-14
To enter capitation payments in MNP (continued):Once patients

have been identified, the Claim Management dialog box is
closed and the Deposit List dialog box is opened.Apply the zero
payment to the patient accounts using the Apply button.In the
Apply Payment/Adjustments to Charges dialog box, enter an
adjustment equal to the outstanding balance.Click the Save
button to record the payments.
Learning Outcome: 11.4 Explain how to enter capitation
payments.
Teaching Notes: Ask students to speculate why there appear to
be so many more steps in applying capitation payments than
applying insurance payments.
Have students complete Exercises 11.5, 11.6, and 11.7.
*
11.5 Appeals, Postpayment Audits, Overpayments, and Billing
Secondary Payers
11-15Appeal—request for reconsideration of a claim
adjudicationUsed to challenge a payer’s decision to deny,
reduce, or otherwise downcode a claimClaimant—person or
entity exercising the right to receive benefitsAppellant —person
who appeals a claim decisionPostpayment audit—review
conducted after a claim is adjudicated
Learning Outcome: 11.5 Discuss the purpose of appeals and
postpayment audits.
Teaching Notes: Walk students through the various
postpayment processes, incorporating the key terms on Slides

15-16 as needed. Discuss again with students the importance of
proper billing and coding up front to avoid situations like these.
Note that most payers have a three-step escalating process of
appeals, which must be started within a specific timeframe. The
process usually involves steps such as the following: 1.
Complaint; 2. Appeal; 3. Grievance.
*
11.5 Appeals, Postpayment Audits, Overpayments, and Billing
Secondary Payers (Continued)
11-16Recovery Audit Contractor (RAC)—entity that audits
Medicare claims to determine where there are opportunities to
recover incorrect payments from previously paid but
noncovered services, erroneous coding, and duplicate
servicesOverpayment—improper or excessive amount received
by provider from payerTakeback—balance that a provider owes
a payer following a postpayment audit
Learning Outcome: 11.5 Discuss the purpose of appeals and
postpayment audits.
Teaching Notes: See notes on Slide 15. Have students
complete Exercise 11.8.
*
11.6 Creating Statements
11-17Patient statement—list of the amount of money a patient
owes, the procedures performed, and the dates the procedures

were performedSent to patients to collect an account balance
that is the patient’s responsibilityExplanation of benefits
(EOB)—document showing how the amount of a benefit was
determined
Learning Outcome: 11.6 Compare standard patient statements
and remainder patient statements.
Teaching Notes: Have students create a compare/contrast sheet
of two of the four main types of patient statements. Have them
(individually or in groups) complete this exercise in class, and
then discuss the results as a large group.
Provide examples to demonstrate when each type of statement is
likely to be created and why.
*
11.6 Creating Statements (Continued)
11-18Standard statements—statements that show all charges
regardless of whether the insurance carrier has paid on the
transactionsRemainder statements—statements that list only
charges that are not paid in full after all insurance carrier
payments have been received
Learning Outcome: 11.6 Compare standard patient statements
and remainder patient statements.
*

11.7 Editing and Printing Statements
11-19In MNP, the Edit button in the Statement Management
dialog box is used to perform edits on account statements.Once-
a-month billing—type of billing in which statements are mailed
to all patients at the same time each monthCycle billing—type
of billing in which statement printing and mailing is staggered
throughout the month
Learning Outcome: 11.7 Explain the difference between once-a-
month and cycle billing.
Teaching Notes: Explain that there are three tabs within the
Statement Management dialog box: General, Transactions, and
Comment. Provide examples of items/information that might go
in each tab; ask students what types of comments might need to
be entered about a statement.
Have students complete Exercises 11.11, 11.12, and 11.13.
*
11.8 Nonsufficient Funds (NSF)
11-20Nonsufficient funds (NSF) check—check that is not
honored by the bank because the account lacks funds to cover
itWhen a practice receives an NSF notice from a bank, an
adjustment is made in the patient’s account.The patient owes
the practice the amount of the returned check.Most practices
charge a fee for a returned check.

Learning Outcome: 11.8 Explain the procedure for processing a
nonsufficient funds payment.
Teaching Notes: An NSF check is more commonly known as a
“bounced” check. Ask students why most practices charge a fee
for a returned check.
*
CHAPTER
McGraw-Hill
9
Checkout Procedures
*
McGraw-Hill
Learning Outcomes
9.1 List the six steps in the charge capture process.
9.2 Explain the purpose of auditing diagnosis and
procedure code assignment.
9.3 Discuss the effect of health plans’ rules on billing.
9.4 Describe the use of CPT/HCPCS modifiers to

communicate billing information to health plans.
9.5 Discuss strategies to avoid common coding/billing errors.
9-2
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McGraw-Hill
9.6 Explain the difference between posting charges from a
paper encounter form and posting charges from an electronic
encounter from.
9.7 Identify the types of payments that may be collected
following a patient’s visit.
9.8 Identify the steps needed to create walkout receipts.
9.9 Describe the use of a patient education feature in an
electronic health record.
9-3
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McGraw-Hill
Key Termsaccept assignmentaddendaadjustmentsbundled
codeCCI column 1/column 2 code pair editsCCI editsCCI
modifier indicatorCCI mutually exclusive code (MEC)
editscharge capture

9-4chargesclaim scrubbingcode linkagecompliant billingCorrect
Coding Initiative (CCI)global periodmedically unlikely edits
(MUEs)modifierMultiLink codes
There are a lot of key terms. Following are some activities to
help present them.
Put students into small groups and assign each group a set of
terms to define and learn. Follow up by having each group
teach their set of terms to the rest of the class.
Assign each student a set number of terms to define as a
homework assignment. Follow up by discussing all of the terms
as a group activity during class.
Ask students whether any of the key terms are familiar to them
already; use their responses to launch a discussion about the
rest of the terms.
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McGraw-Hill
Key Terms (Continued)packagepaymentsplace of service (POS)
codequeryreal-time claim adjudication (RTCA)self-pay
patientsunbundlingwalkout receipt
9-5
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McGraw-Hill

9.1 Overview: Charge Capture Process
9-6Charge capture—process of recording billable servicesThe
six steps of the charge capture process:Step 1: Access
encounter data.Step 2: Audit coding compliance.Step 3:
Review billing compliance.Step 4: Post charges.Step 5:
Calculate, collect, and post time-of-service (TOS)
payments.Step 6: Check out patient.
Learning Outcome: 9.1 List the six steps in the charge capture
process.
Teaching Notes: Ask students why they believe the charge
capture process needs to be done in the order shown; use
responses as a springboard into discussion.
Compare and contrast the electronic method of charge capture
with the paper method. Discuss the pros and cons of each.
As a group, complete “Thinking It Through” 9.1 to solidify
concepts.
If desired, assign students a second scenario similar to
“Thinking It Through” 9.1 to complete on their own as
reinforcement.
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McGraw-Hill
9.1 Overview: Charge Capture Process (Continued)
9-7Charges—amount a provider bills for performed health care
servicesPayments—money paid by patients and health

plansAdjustments—changes to a patient’s account
Learning Outcome: 9.1 List the six steps in the charge capture
process.
Teaching Notes: These are key terms, so they may already have
been defined/discussed. If so, see notes on Slide 6. If not, go
through each term and relate it to the charge capture process
steps.
*
McGraw-Hill
9.2 Coding Compliance
9-8Physician practices audit medical coding to ensure maximum
appropriate reimbursementCodes/claims must be current and
accurate for reimbursement.Code linkage and medical necessity
must be shown.Addenda—updates to ICD-9-CMClaim
scrubber—software that checks claims to permit error
correctionCode linkage—clinically appropriate connection
between a provided service and a patient’s condition or illness
Learning Outcome: 9.2 Explain the purpose of auditing
diagnosis and procedure code assignment.
Teaching Notes: It is IMPORTANT TO NOTE that
PHYSICIANS are ultimately responsible for coding compliance,
even though they do not do the actual work. Discuss this with
students – why is this the case? Is it fair? Why or why not?
What could physicians do to protect themselves from non-
compliance?

When discussing the addenda to ICD-9, note that the code set is
updated annually. What does this mean for billers/coders?
Use the screenshots in the textbook to walk students through
how payments, adjustments, and changes are handled through
Medisoft Network Professional.
Assign students Exercises 9.1 and 9.2.
*
McGraw-Hill
9.3 Billing Compliance
9-9Health plans and government payers reimburse practices
according to their own negotiated or government-mandated fee
schedule.Health plans issue many billing rules that govern what
will and will not be covered.Medical practices must comply to
be reimbursed.Compliant billing—billing actions that satisfy
official requirementsPackage—combination of services included
in a single procedure code
Learning Outcome: 9.3 Discuss the effect of health plans’ rules
on billing.
Teaching Notes: It is IMPORTANT to explain to students that
noncompliant billing may be seen as FRAUD. Ask them why;
discuss.
Explain that noncompliant billing may lead to any or all of the
following for a practice, physician (again, since they are
ultimately responsible for compliance), or staff member: delays

in claim processing/receiving payments, reduced payments,
denied claims, fines/sanctions, loss of hospital privileges,
exclusion from health plan programs, loss of licensing, prison.
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McGraw-Hill
9.3 Billing Compliance (Continued)
9-10Bundled code—two or more related procedure codes
combined into oneGlobal period—days surrounding a surgical
procedure when all services relating to the procedure are
considered part of the surgical packageCorrect Coding Initiative
(CCI)—computerized Medicare system that prevents
overpaymentCCI edits—CPT code combinations that are used
by computers to check Medicare claims
on billing.
Teaching Notes: Focus on the CCI, which is updated every
quarter; use Figure 9.12 in the text for reference. Stress the key
terms associated with the CCI (on subsequent slides as well)
and provide as many examples as possible to reinforce terms
with students. The textbook has many figures and examples
useful for facilitating discussion.
If possible, have coding books/CCI addenda/etc. available in
class for students to review. Consider a group activity or
assignment that involves students’ checking sample coding
scenarios for compliance. For example, you could present three
procedures which have been coded individually when there is a
bundled code for the entire process (“unbundling” is covered on
Slide 11).

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McGraw-Hill
9-11Unbundling—incorrect billing practice of breaking a panel
or package of services/procedures into component partsCCI
column 1/column 2 code pair edits—Medicare code edit in
which CPT codes in column 2 will not be paid if reported for
same day of service, for the same patient, and by the same
provider as the column 1 code
on billing.
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McGraw-Hill
9-12CCI mutually exclusive code (MEC) edits—edits for codes
for services that could not have reasonably been done during
one encounterMedically unlikely edits (MUEs)—units of service
edits used to lower the Medicare fee-for-service paid claims
error rate
on billing.

*
McGraw-Hill
9.4 Modifiers
9-13Modifier—number appended to a code to report particular
factsCommunicates special circumstances involved with
procedures.Tells the health plan that the physician considers the
procedure to have been altered in some way.There are both CPT
and HCPCS modifiers.CCI modifier indicator—number showing
whether the use of a modifier can bypass a CCI edit
Learning Outcome: 9.4 Describe the use of CPT/HCPCS
modifiers to communicate billing information to health plans.
Teaching Notes: Use Tables 9.1 and 9.2 in the text as a
reference and guide for this discussion. Explain that modifiers
are mainly needed for situations like the following: a
service/procedure was performed multiple times or by more than
one physician; a service/procedure has been increased or
reduced; only part of a procedure was done; unusual difficulties
occurred during the procedure.
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McGraw-Hill
9.5 Strategies to Avoid Common Coding/Billing Problems
9-14Compliance errors can result from incorrect code selection
or billing practices.Strategies for compliance include:carefully
defining bundled codes and knowing global periods,using

modifiers appropriately, andfollowing the practice’s compliance
plan, especially the guidelines about physician queries.
Learning Outcome: 9.5 Discuss strategies to avoid common
coding/billing errors.
Teaching Notes: Have students discuss ways to avoid errors
such as truncated codes, billing invalid/outdated codes,
upcoding, or downcoding.
Explain again that the coding process is usually the ONLY way
health plans/insurance companies decide whether or not to
reimburse.
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McGraw-Hill
9.5 Strategies to Avoid Common Coding/Billing Problems
(Continued)
9-15Place of service (POS) code—designates location where
medical services were providedQuery—request for more
information from a provider
Learning Outcome: 9.5 Discuss strategies to avoid common
coding/billing errors.
Teaching Notes: See notes on Slide 14. If more coverage of
these key terms is needed, provide examples for students; for
instance, point out that a query might be needed when there is
conflicting or ambiguous information.
*

McGraw-Hill
9.6 Posting Charges in Medisoft
9-16Process of posting charges differs when using a paper
encounter form versus an EHR.Posting charges from a paper
encounter form:Click the New button in the Transaction Entry
dialog box.Complete the required fields.Apply the payment in
the Charges Area of the Transaction Entry dialog box.Save the
charges using the Save Transactions button.MultiLink codes—
groups of procedure code entries that relate to a single activity
Learning Outcome: 9.6 Explain the difference between posting
charges from a paper encounter form and posting charges from
an electronic encounter from.
Teaching Notes: Explain what the “required fields” are when
discussing posting charges; use textbook pages 456-460 as a
guide. Discuss why the information is required rather than being
optional.
Be sure to explain the different color-coding references
(partially paid claims are aqua, etc.) in the Transaction section.
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McGraw-Hill
9.6 Posting Charges in Medisoft

Network Professional (Continued)
9-17Posting charges from an EHR:Transactions from an EHR do
not need to be manually posted in the Transaction Entry dialog
box.After electronic encounter form data is reviewed and edited
(if necessary), it is posted and automatically appears in the
Transaction Entry dialog box.Unprocessed transactions can be
posted from the Unprocessed Charges dialog box or from the
Unprocessed Transactions Edit dialog box.
Learning Outcome: 9.6 Explain the difference between posting
charges from a paper encounter form and posting charges from
an electronic encounter from.
Teaching Notes: Ask students why, if posting charges from an
EHR is so much quicker, there is still a need to manually enter
paper claims (because not every practice is using EHRs yet,
etc.)
Give student an assignment (either in groups or individually) to
research reimbursement rates, fraud, or other transaction
scenarios in terms of paper encounter forms versus EHR
information. Ask them to write up a brief summary of their
findings, with examples – did they notice anything in terms of
the accuracy/reliability of EHR records versus paper records?
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McGraw-Hill
9.7 Posting Patient Time-of-Service Payments
9-18Practices routinely collect payment for the following types

of charges at the time of service:Previous balancesCopayments
or coinsuranceNoncovered or overlimit feesCharges of
nonparticipating providersCharges for self-pay
patientsDeductibles for patients with consumer-driven health
plans (CDHPs)
Learning Outcome: 9.7 Identify the types of payments that may
be collected following a patient’s visit.
Teaching Notes: Ask students why these types of payments are
collected at time of service; discuss what might happen if these
payments are not collected at this time.
If desired, integrate this section’s key terms (on next slide) into
this discussion; terms might make more sense if they are
discussed in context.
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McGraw-Hill
9.7 Posting Patient Time-of-Service Payments (Continued)
9-19Accept assignment—participating physician’s agreement to
accept allowed charge as full paymentSelf-pay patients—
patients with no medical insuranceReal-time claim adjudication
(RTCA)—process used to contact health plans electronically to
determine visit charges
Learning Outcome: 9.7 Identify the types of payments that may
be collected following a patient’s visit.
Teaching Notes: When discussing “accept assignment,” note

that the procedure for collecting nonPAR payment is different:
usually the patient needs to pay everything up front. Ask
students why this is the case.
Discuss the actual process for using RTCA (see textbook pages
471-472).
Before assigning exercises, walk through the process of entering
payment information in Medisoft Network Professional with
students.
Reinforce the color-coded payment key (gray, yellow, aqua).
Ask students to complete Exercises 9.8 and 9.9.
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McGraw-Hill
9.8 Creating Walkout Receipts
9-20Walkout receipt—report that lists the diagnoses, services
provided, fees, and payments received and due after an
encounterTo create a walkout receipt in MCPR:Click the Print
Receipt button in the Transaction Entry dialog box; the Open
Report window appears.Click the OK button; the Print Report
Where? Dialog box is displayed.Make a selection, and click the
Start button.Click the OK button to send the report to its
destination.
Learning Outcome: 9.8 Identify the steps needed to create
walkout receipts.
Teaching Notes: Ask students to brainstorm why walkout
receipts are a good idea. In their experience, does every practice

provide walkout receipts? Why or why not?
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McGraw-Hill
9.9 Printing Patient Education Materials
9-21It may be appropriate to give patients education materials
during checkout in order to:help patients better understand their
diagnoses and treatments, and provide instructions following an
office procedure.The patient education feature of MCPR
provides a built-in set of patient education articles that can be
printed and given to patients.
Learning Outcome: 9.9 Describe the use of a patient education
feature in an electronic health record.
Teaching Notes: Have students brainstorm what types of
information might be given to patients (an article on blood
pressure, information on reduced sodium diets, etc.). Have
students discuss the benefits of providing this information to
patients at the office, rather than saying “look it up when you
get home,” or taking time during an appointment to explain
everything.
Highlight the usefulness of MCPR’s built-in database of
materials – no need to look elsewhere! Note that the database
contains sets of articles for pediatrics, adults, seniors, women,
and behavioral health.
MCPR can automatically select the proper module based on
patient information and demographics if desired.

Articles can be emailed or printed in-office (discuss
benefits/drawbacks of each method).
*
CHAPTER
McGraw-Hill
13
Accounts Receivable Follow-up and Collections
*
Learning Outcomes
13.1 Explain why it is important to collect overdue
balances from patients.
13.2 Describe the way in which financial policies help
establish payment expectations.
13.3 Describe the procedures followed to identify overdue
accounts.
13.4 Identify the major federal laws that govern the
collection process.
13.5 Explain how letters are used in collecting overdue
payments.

13-2
*
13.6 Explain payment plans.
13.7 Discuss the use of collection agencies to pursue patients
who have not paid overdue bills.
13.8 Describe the procedures for clearing uncollectible
balances and small balances from patients’ accounts
receivable.
13-3
*
Key Termsbankruptcycollection agencycollection listcollection
tracer reportEqual Credit Opportunity Act (ECOA)Fair Debt
Collection Practices Act of 1977 (FDCPA)means test
13-4patient refundpayment plansmall-balance accountTelephone
Consumer Protection Act of 1991ticklerTruth in Lending
Actuncollectible accountwrite-off
Teaching Notes: There are a lot of key terms, but many of them
might already be familiar to your students. Give a pop quiz of

the terms to see how many students know. Grade the quiz in
class and use the results to focus your lecture on terms that
*
13.1 The Importance of Collections
from Patients
13-5Receiving full payment for services is a critical factor in
determining the financial success of a medical practice.Sums
that are not collected must be subtracted from income, reducing
working capital.If payments are not collected, the practice may
have to borrow funds and pay interest on those amounts.The
average patient is now responsible for paying nearly 35 percent
of their medical bills.
Learning Outcome: 13.1 Explain why it is important to collect
overdue balances from patients.
Teaching Notes: Since members of the practice’s staff may be
asked to work with patients to aid in collections, have students
role-play some customer scenarios in which they try to obtain
payment from a past-due patient.
Have students brainstorm some ways a practice could cut down
on the number of collections they experience.
*
13.2 The Financial Policy and Payment Expectations

13-6The patient collection process begins with a clear financial
policy.Clear financial policies:result in effective
communications with patients about their financial
responsibilities,help patients to understand the charges and the
practice’s policies in advance,make collecting payments less
problematic,enable practices to add finance charges on late
accounts, when announced in advance.
Learning Outcome: 13.2 Describe the way in which financial
policies help establish payment expectations.
Teaching Notes: Ask students how a clear financial policy will
make collecting payments less problematic.
Explain that it is acceptable for a practice’s financial policy to
stipulate the addition of finance charges on past-due payments,
as long as the finance charge penalty complies with state and
federal law.
*
13.3 Collection Procedures
13-7Nonpayment of patient statements initiates the collection
process.Patient aging reports are analyzed to determine which
patients are overdue on their bills and to group them into
categories for efficient collection efforts.Collection list—tool
for tracking activities that need to be completed as part of the
collection processTickler—reminder to follow up on an
accountIn MNP, selections for the Collection List feature are
located on the Activities menu.
Learning Outcome: 13.3 Describe the procedures followed to

identify overdue accounts.
Teaching Notes: Explain that many practices send an
outstanding bill to collections after 90 days; the text mentions
that some practices send to collections as soon as 30 days out.
Why might this be the case? Is there an advantage to sending a
bill to collections sooner? Later?
*
13.4 Laws Governing Patient Collections
13-9Collections from patients are classified as consumer
collections and are regulated by federal and state laws.Fair Debt
Collection Practices Act of 1977 (FDCPA)—federal law
regulating collection practicesTelephone Consumer Protection
Act of 1991—federal law regulating collection practices
Learning Outcome: 13.4 Identify the major federal laws that
govern the collection process.
Teaching Notes: Go through the best practices for contacting
patients on page 647 of the textbook; elicit student feedback on
the fairness and completeness of the points.
*
13.5 Collection Letters
13-10Collection letters are usually a patient’s first notice that
their bill is past due. These letters:are brief and to the

point,preserve a professional and courteous tone,remind the
patient of the practice’s payment options,remind the patient of
their responsibility to pay the debt.Collection tracer report—
tool for keeping track of collection letters that were sent
Learning Outcome: 13.5 Explain how letters are used in
collecting overdue payments.
Teaching Notes: Direct students’ attention to Figure 13.16 in
the textbook to showcase an account which has been flagged.
Have students draft a sample collection letter to a patient; use
the letter as a springboard into discussion. Is it an advantage or
a disadvantage to have MNP generate automatic collection
letters? Why?
*
13.6 Payment Plans
13-11Payment plan—agreement between a patient and a practice
in which the patient agrees to make regular monthly payments
over a specified time periodMost practices have a number of
different payment plan options.If a payment plan is assigned
and followed by the patient, the patient will not be sent
collection letters.Payment plans may be regulated by law.
Learning Outcome: 13.6 Explain payment plans.
Teaching Notes: Practices’ payment plans may be regulated by
date, frequency of payment, or amount of payment. Usually, the

amount of the debt plays a role in figuring out a payment plan.
*
13.6 Payment Plans (Continued)
13-12Equal Credit Opportunity Act (ECOA)—law that prohibits
credit discrimination on the basis of race, color, religion,
national origin, sex, marital status, or age, or because a person
receives public assistanceTruth in Lending Act—part of the
federal Consumer Credit Protection Act that regulates collection
practices related to finance charges and late fees
Learning Outcome: 13.6 Explain payment plans.
Teaching Notes: Ask students to discuss why it is important to
have regulations surrounding payment plans and collections – if
a person owes money to a practice, shouldn’t the practice be
allowed to set its own policies? Discuss how discrimination
might be shown to one of the classes protected under the ECOA.
*
13.7 Collection Agencies
13-13Collection agency—outside firm hired to collect on
delinquent accountsPractices should select agencies that have a
reputation for fair and ethical handling of collections.Collection
agencies are often paid on the basis of the amount of money
they collect.Office staff members no longer contact patients
whose accounts have been referred to a collection agency.

Learning Outcome: 13.7 Discuss the use of collection agencies
to pursue patients who have not paid overdue bills.
Teaching Notes: Ask students why an office staff member
would no longer contact a patient whose accounts have been
turned over to collections.
*
13.8 Write-Offs and Refunds
13-14Uncollectible account—account that does not respond to
collection efforts and is written off the practice’s expected
accounts receivableMeans test—process of fairly determining a
patient’s ability to payBankruptcy—declaration that a person is
unable to pay his or her debtsWrite-off—balance that has been
removed from a patient’s account
Learning Outcome: 13.8 Describe the procedures for clearing
uncollectible balances and small balances from patients’
accounts receivable.
Teaching Notes: Discuss the impact an uncollectible account
would have on the financial strength of a practice.
Define each of the situations/terms on Slides 14-15 and provide
examples of each; ask students to debate which situations could
be most easily addressed or mitigated.
*

13.8 Write-Offs and Refunds (Continued)
13-15Small-balance account—overdue patient account in which
the amount owed is less than the cost of pursuing
paymentPatient refund—money owed to the patientUncollectible
balances may be removed from patients’ accounts receivable
using MNP’s Transaction Entry dialog box.Small balances may
be removed using MNP’s Small Balance Write-off feature from
the Activities menu.
Learning Outcome: 13.8 Describe the procedures for clearing
uncollectible balances and small balances from patients’
accounts receivable.
Teaching Notes: See notes on Slide 14; have students complete
Exercises 13.7, 13.8, and 13.9.
*
CHAPTER
McGraw-Hill
7
Office Visit: Examination and Coding
*

Learning Outcomes
7.1 Discuss the methods of entering documentation in an
EHR.
7.2 Compare the process of entering a progress note with
and without using a template.
7.3 Explain why e-prescribing reduces some medical errors.
7.4 List the steps required to enter a new prescription.
7.5 Explain why ordering and receiving test results
electronically is more efficient than using paper
methods.
7.6 List the steps required to enter an electronic order.
7-2
*
7.7 Explain how orders are processed in an EHR.
7.8 Define medical coding.
7.9 Discuss the purpose of ICD-9-CM.
7.10 Discuss the purpose of the CPT/HCPCS code sets.
7.11 Demonstrate the process that is followed to select a
correct evaluation and management code.
7.12 Compare coding in a paper-based office with coding in
an office with an EHR.
7.13 Discuss the purpose of an electronic encounter form in
an EHR.
7-3

*
Key TermsAlphabetic IndexCategory I codesCategory II
codesCategory III codescomputer-assisted codingCurrent
Procedural Terminology (CPT)dictationdigital
dictationelectronic encounter form (EEF)
7-4evaluation and management (E/M)
codesformularyHCPCSICD-9-CMICD-9-CM Official Guidelines
for Coding and ReportingICD-10-CMkey componentsmedical
coding
Teaching Notes: Many of these terms deal with coding, which
might be a new topic for many students. As much as possible,
explain the terms and provide examples so students can make
connections.
OPTIONS: After you have gone over the basics of coding, have
students/student groups research a set number of terms and
present their findings to the class. Provide specific examples
(of an instance of upcoding, for example) and see if students
can match the examples to the correct terms.
*
Key Terms (Continued)primary diagnosisSOAPTabular
Listtemplateupcodingvoice recognition software

7-5
*
7.1 Methods of Entering Physician Documentation in an EHR
7-6Dictation—process of recording spoken words that will later
be transcribed into written formTraditional method of
documenting patient encountersDigital dictation—process of
dictating using a microphone, a headset connected to a
computer, a smart phone, or a PDAVoice recognition software—
software that recognizes spoken wordsTemplate—preformatted
file that serves as a starting point for a new document
Learning Outcome: 7.1 Discuss the methods of entering
documentation in an EHR.
Teaching Notes: Note that U.S. physicians create more than
ONE BILLION clinical notes each year. Use this information to
transition into a discussion of the benefits of an EHR.
Direct students’ attention to Figures 7.1, 7.2, and 7.3 in the
text, which compare various ways for dictating and transcribing
information. Discuss the advantages and disadvantages of each
method.
*
7.2 Progress Notes in Medisoft Clinical Patient Records

7-7Progress notes can be entered using dictation and
transcription, voice recognition software, or templates, or with a
combination of techniquesSOAP—format used to enter progress
notes; stands for subjective, objective, assessment, and plan
Learning Outcome: 7.2 Compare the process of entering a
progress note with and without using a template.
Teaching Notes: Present a selection of patient encounters, and
give students (either individually or in groups) the assignment
of creating a brief SOAP note for their assigned encounter.
Discuss the results as a class.
*
7.2 Progress Notes in Medisoft Clinical Patient Records
(Continued)
7-8To create a progress note:A patient chart must be open.Click
the Note button on the toolbar and enter the date and title.Then
choose from one of the documentation entry methods.If using a
template, it will be inserted in the note; the physician responds
to its labels accordingly to complete the note.If not using a
template, the information is typed freely by the physician.
Learning Outcome: 7.2 Compare the process of entering a
progress note with and without using a template.
Teaching Notes: Ask students to brainstorm the reasons behind
using or not using a template – why would one be better than
the other? What does it depend upon? Are there any drawbacks
to using a template?

Us the figures from the text to show examples of what a
progress note in MCPR looks like at various stages.
*
7.3 E-Prescribing and Electronic Health Records
7-9E-prescribing reduces some medical errors by:avoiding many
of the mistakes that occur with handwritten
prescriptions,providing a number of built-in safety checks,
andchecking to be sure the medication is in the formulary of a
patient’s health plan.
Formulary—list of a plan’s selected drugs and their proper
dosages
Learning Outcome: 7.3 Explain why e-prescribing reduces some
medical errors.
Teaching Notes: Ask students to think about how prescription
safety checks and refilling were done before the days of e-
prescribing. Use Figures 7.10 and 7.11 for assistance. What
concerns are associated with the “old way”? Are there any
benefits to doing safety checks without the benefit of
technology? Ask: As a patient, would you rather your medicine
be e-prescribed or checked and filled manually? Why?
*

7.4 Entering Prescriptions in Medisoft Clinical Patient Records
7-10
To enter a new prescription in MCPR:Start from the
Rx/Medications folder in a chart, or click the Rx button; the
Prescription dialog box will be displayed.Complete the fields in
the Prescription dialog box.Review the ten check boxes in the
dialog box.Click the OK button to save the current prescription.
Learning Outcome: 7.4 List the steps required to enter a new
prescription.
Teaching Notes:
Note that a PIN is needed to transmit prescriptions. Why?
MCPR monitors ALL patient prescriptions – new, ineffective,
and historical (review those terms with students).
Point out the dose Calculator button, another Medisoft function
that calculates doses based on patient weight and the 10
required check boxes that ensure prescription accuracy.
*
7.5 Ordering Tests and Procedures
in an EHR
7-11
Electronic order entry is more efficient than paper methods as
it:reduces errors associated with handwritten and paper
orders,provides numerous safety and cost-control
benefits,allows the user to delay sending out orders until

approval is received, andallows orders to be printed or
transmitted electronically.
In addition, MCPR is capable of checking orders against
information specific to a patient.
Learning Outcome: 7.5 Explain why ordering and receiving test
results electronically is more efficient than using paper
methods.
Teaching Notes: Explain that some EHRs have built-in standard
order sets for common procedures, and while many large
practices have lab facilities on-site, most small practices must
outsource all of their lab work. Thankfully, if the practice uses
an EHR, the EHR can receive lab results electronically.
Ask students to compare and contrast Figures 7.13 and 7.14.
Which do they prefer? Why?
*
7.6 Order Entry in Medisoft Clinical
Patient Records
7-12In MCPR, physicians can enter orders for laboratory,
radiology, pathology, and other diagnostic tests.To enter an
electronic order in MCPR:Click on the Orders folder in the
patient’s chart; the Orders dialog box is displayed.Click the
New button to enter a new order; the Order dialog box will
open.Complete the four sections of the Order dialog box.Click
OK to record the orders.

Learning Outcome: 7.6 List the steps required to enter an
electronic order.
Teaching Notes: Orders are automatically listed at the end of a
progress note, if tests were ordered the same day a patient was
seen.
Have students discuss why the “panel” option is a nice function
– user can order a whole panel rather than multiple single tests.
Relate these panels to those in CPT, Lab and Path code section.
Show students Figures 7.16 and 7.17 to point out the Order
Tree.
*
7.7 Order Processing in Medisoft Clinical Patient Records
7-13To process an order:In MPCR, select Orders > Order
Processing on the Task menu; the Order Processing Select
screen appears, with the Select Orders dialog box on top.Use
the filters in the Select Orders dialog box.The Order Processing
Select dialog box will display the orders that meet the criteria
selected.Click the Edit button to view an order before it is
processed.To print an order for a patient, click the Forms
button; then click the OK button on the Standard Orders
Printing Select dialog box which appears.
Learning Outcome: 7.7 Explain how orders are processed in an
EHR.

Teaching Notes: Walk students through the order processing
process using the screenshots in the textbook for assistance and
examples. Ask students why there appear to be so many steps
to go through to process an order.
When discussing the Order Processing Select dialog box,
identify all pieces of information that are displayed: date and
time of order entry, patient name and ID, order name and status,
PVID, order set, facility, and whether or not the order is a
repeat.
*
7.7 Order Processing in Medisoft Clinical Patient Records
(Continued)
7-14To process an order (continued):To send an order
electronically, right click the line that contains the order; a
menu will appear.Select the appropriate options from the
menu.Click the OK button to send the order.Once the order has
been printed or sent electronically, its status will change from
pending to sent.To view orders that have been sent, select Sent
as the Order Status in the Select Orders dialog box.
Learning Outcome: 7.7 Explain how orders are processed in an
EHR.
*

7.8 Medical Coding Basics
7-15Medical coding—process of applying the HIPAA-mandated
code sets to assign codes to diagnoses and proceduresIn the
physician practice coding environment, the required code sets
are:CPT (Current Procedural Terminology)HCPCS (Healthcare
Common Procedure Coding System)ICD-9-CM (International
Classification of Diseases, Ninth Revision, Clinical
Modification)
Learning Outcome: 7.8 Define medical coding.
Teaching Notes: Have sample coding books available, and let
students page through them while discussing coding basics.
Have students debate the pros and cons of using medical codes
to classify diagnoses and procedures. Ask why the code sets are
divided between diagnoses and procedures.
Discuss the fact that coding is directly tied to reimbursement.
If possible, give examples of proper and improper coding and
the results that come from each.
Give examples of coding scenarios and have students guess if
the claim was reimbursed or not. Ask them to justify their
thoughts.
*
7.9 Diagnostic Coding
7-16Primary diagnosis—patient’s major illness or condition for
an encounterICD-9-CM—abberivated title of International

Classification of Diseases, Ninth Revision, Clinical
Modification, the source of the codes used for reporting
diagnosesUsed to code and classify morbidity data from patient
medical records, physician offices, and national surveys
Learning Outcome: 7.9 Discuss the purpose of ICD-9-CM.
Teaching Notes: Explain to students that expertise in diagnostic
coding requires knowledge of medical terminology,
pathophysiology, and anatomy, as well as experience in
applying coding guidelines. Ask students why a coder would
need expertise in medical terms and pathologies in addition to
coding knowledge.
*
7.9 Diagnostic Coding (Continued)
7-17The ICD-9-CM code set has three parts:Diseases and
Injuries: Tabular List—Volume 1Diseases and Injuries:
Alphabetic Index—Volume 2Procedures: Tabular List and
Alphabetic Index—Volume 3Tabular List—section of the ICD-
9-CM listing diagnosis codes numericallyAlphabetic Index—
section of the ICD-9-CM alphabetically listing diseases and
injuries with corresponding diagnosis codes
Teaching Notes: Explain to students which volumes (1 and 2)
are for outpatient and which (3) is for inpatient coding. When
might a coder use the tabular list versus the alphabetic list?

Reference Figure 7.22 in the text, which is a flowchart of the
diagnostic coding process.
Discuss with the class the reasons for so many segmentations in
use, type, and classification of ICD-9-CM codes.
*
7.9 Diagnostic Coding (Continued)
7-18ICD-9-CM Official Guidelines for Coding and Reporting—
American Hospital Association publication that provides rules
for selecting and sequencing diagnosis codesICD-10-CM—
abbreviate title of International Classification of Diseases,
Tenth Revision, Clinical Modification, which will be used
beginning in 2013Provides many more categories for disease
and other health-related conditions and much greater flexibility
for adding new codes
Teaching Notes: Note that the WHO put out the ICD-10 code set
in 1990, but the United States is only now beginning the
transition. Ask students to debate why the delay might have
occurred and whether or not it was a good idea to stay with the
ICD-9 for so long.
Ask students to put together a short research paper looking at
the differences and challenges associated with ICD-9 and ICD-
10; they should also look at the education/refreshers needed to
aid in the transition.
*

7.10 Procedural Coding
7-19Procedure codes are used by physicians to report the
medical, surgical, and diagnostic services they provide.Current
Procedural Terminology (CPT)—standardized classification
system for reporting medical procedures and servicesHCPCS—
procedure codes for Medicare claims
Learning Outcome: 7.10 Discuss the purpose of the CPT/HCPCS
code sets.
Teaching Notes: Explain that procedure codes are used to help
implement best practices; researchers track the results of
various treatment plans and report them to physicians.
CPT = procedures and servicesHCPCS (hick picks) = supplies
and equipment
*
7.10 Procedural Coding (Continued)
7-20There are three categories of CPT codes:Category I codes —
procedure codes found in the main body of CPTCategory II
codes—optional CPT codes that track performance
measuresCategory III codes—temporary codes for emerging
technology, services, and procedures
Learning Outcome: 7.10 Discuss the purpose of the CPT/HCPCS
code sets.

Teaching Notes: Give a number of examples of things that
would fall into each code category so students can make
connections. Then, call out various issues and procedures and
see if students can properly categorize them (reducing tobacco
use = Category II code).
NOTE: Explain that Category III codes may become permanent
and part of the regular code set if the emerging service proves
effective.
As an optional in-class assignment, have students use the
Internet to research some Category III codes that have been
added to the regular code set.
*
7.11 Evaluation and Management (E/M) Codes
7-21Evaluation and management (E/M) codes—codes that cover
physicians’ services performed to determine the optimum course
for patient careTo select the correct E/M code, eight steps are
followed:Step 1: Determine the category and subcategory of
service based on the place of service and the patient’s
status.Step 2: Determine the extent of the history that is
documented.Step 3: Determine the extent of the examination
that is documented.
Learning Outcome: 7.11 Demonstrate the process that is
followed to select a correct evaluation and management code.
Teaching Notes: Explain that E/M codes are a subset of CPT
codes; they reflect a range of analysis and decision-making,

from low to high. (Provide examples to students to enhance
connections). Each range is tied to an increasingly higher
payment level.
Use the flowchart in the textbook (Figure 7.24) to illustrate the
8 steps of choosing an E/M code.
*
7.11 Evaluation and Management (E/M) Codes (Continued)
7-22Selecting the correct E/M code (continued):Step 4:
Determine the complexity of medical decision making that is
documented.Step 5: Analyze the requirements to report the
service level.Step 6: Verify the service level based on the
nature of the presenting problem, time, counseling, and care
coordination.Step 7: Verify that the documentation is
complete.Step 8: Assign the code.Key component—factors
documented for various levels of E/M services
Learning Outcome: 7.11 Demonstrate the process that is
followed to select a correct evaluation and management code.
Teaching Notes: Provide sample scenarios to student groups,
and have each group walk through the 8 steps of determining
and assigning the codes. Discuss results as a whole class.
*
7.12 Coding Methods

7-23Coding in a paper-based office:Provider writes or dictates
notes either during or after the examination.Written notes are
filed in the patient’s chart; dictated notes must be transcribed
and then reviewed for accuracy by the provider.Coder reviews
the provider’s documentation and assigns codes for the patient’s
diagnoses and for the services provided.Once codes are
assigned, the encounter forms are forwarded to a billing
department, where the staff manually enters the information into
the PM system.
Learning Outcome: 7.12 Compare coding in a paper-based
office with coding in an office with an EHR.
Teaching Notes: The typical coding/billing/reimbursement
cycle takes anywhere from 3-14 days. It is estimated that some
practices lose up to 10% of revenue due to manual billing
errors. Coding is done by a member of office’s coding staff.
*
7.12 Coding Methods (Continued)
7-24Coding in an office with an EHR:Provider documents the
visit in the EHR.EHR assigns preliminary codes based on the
documentation.Coder reviews the EHR-generated codes for the
patient’s diagnosis and for the services provided and assigns a
diagnosis code to each procedure code.Coder instructs the EHR
to transmit the encounter information electronically to the PM
system.

Teaching Notes: Normally, some part of the process is
automated. Turnaround is much quicker since the computer
system flags a lack of information for determining code sets.
The user can search for codes by entering keywords and
information into the system.
Have students compare and contrast Figures 7.25 and 7.26.
What differences do they see?
Be sure to cover the warnings for coding in an EHR office –
risk for committing fraud (ask students how this is so),
inaccurate code submission.
*
7.12 Coding Methods (Continued)
7-25Computer-assisted coding—assigning preliminary diagnosis
and procedure codes using computer software Upcoding—
assigning a higher level code than is supported by
documentation
Teaching Notes: Assign students a short paper discussing the
pros and cons of a paper-based coding system versus
computer/EHR coding.
IMPORTANT: Stress the negative implications of upcoding,
how it can be avoided, and whether or not it is always
intentional.

*
7.13 Coding in Medisoft Clinical Patient Records
7-26
Electronic encounter form (EEF)—electronic version of the
form that lists procedures and charges for a patient’s visitIt
eliminates the need for paper encounter forms.It is
automatically populated with preliminary codes derived from
information in the progress note in the EHR.Its codes are
reviewed by a coding specialist.
Learning Outcome: 7.13 Discuss the purpose of an electronic
encounter form in an EHR.
Teaching Notes: Explain that MCPR’s coding function is
employed after the EEF is completed and reviewed. Point out
the Action Item tab in MCPR (reference Figure 7.29) and note
that if there is an outstanding action item, a claim cannot be
transmitted.
Ask students: If electronic coding is supposed to reduce errors,
aid in reimbursement, and streamline the coding process, why
does a coding specialist need to review all codes? Doesn’t that
seem counterintuitive?
*

CHAPTER
McGraw-Hill
10
Claim Management
*
Learning Outcomes
10.1 Briefly compare the CMS-1500 paper claim and the
837 electronic claim.
10.2 Discuss the information contained in the Claim
Management dialog box.
10.3 Explain the process of creating claims.
10.4 Describe how to locate a specific claim.
10.5 Discuss the purpose of reviewing and editing claims.
10.6 Analyze the methods used to submit electronic claims.
10-2
*
10.7 List the steps required to submit electronic claims.

10.8 Describe how to add attachments to electronic claims.
10.9 Explain the claim determination process used by health
plans.
10.10 Discuss the use of the PM/EHR to monitor claims.
10-3
*
Key Termsadjudicationagingclaim status category codesclaim
status codesclaim turnaround timeCMS-1500 (08/05)
claimcompanion guidecrossover claimdata
elementsdetermination
10-4developmentfilterHIPAA X12 837 Health Care
ClaimHIPAA X12 276/277 Health Care Claim Status
Inquiry/Responseinsurance aging reportmedical necessity
denialNational Uniform Claim Committee (NUCC)navigator
buttons
Teaching Notes: There are a lot of key terms, but many of
them might already be familiar to your students. Give a pop
quiz of the terms to see how many students know. Grade the
quiz in class and use results to focus your lecture on terms that
*
Key Terms (Continued)pendingprompt payment

lawssuspendedtimely filing
10-5
*
10.1 Introduction to Health Care Claims
10-6Timely filing—health plan’s rules specifying the number of
days after the date of service that the practice has to file the
claimHIPAA X12 837 Health Care Claim—HIPAA standard
format for electronic transmission of the claim to a heal th
planCMS-1500 (08/05) claim—mandated paper insurance claim
formNational Uniform Claim Committee (NUCC)—organization
responsible for claim content
Learning Outcome: 10.1 Briefly compare the CMS-1500 paper
claim and the 837 electronic claim.
Teaching Notes: Provide sample completed insurance claim
forms that contain errors and have student groups pinpont the
errors. Discuss as a class and reinforce the fact that clean
claims are critical to proper reimbursement.
Ask students why they think that, in the era of electronic
records, the CMS-1500 is a mandated paper form.
*
10.1 Introduction to Health Care Claims (Continued)

10-7Data element—smallest unit of information in a HIPAA
transactionNotable features of the HIPAA 837 transaction (as
compared to the CMS-1500 paper form):It has many more data
elements, though many are conditional and apply to particular
specialties only.It uses some different terms, and a few
additional information items must be relayed to the payer.It
requires a claim filing indicator code.
Learning Outcome: 10.1 compare the CMS-1500 paper claim
and the 837 electronic claim.
Teaching Notes: When discussing the differences between
HIPAA 837 and the CMS-1500, cite what some of the “many
more data elements” are and why they are required.
*
10.2 Claim Management in Medisoft Network Professional
10-8Insurance claims are created, edited, and submitted for
payment within the Claim Management area of
MNP.Information contained in the Claim Management dialog
box:All claims that have already been createdStatus of existing
claimsOptions for editing, creating, printing/sending,
reprinting, and deleting claimsNavigator buttons—buttons that
simplify the task of moving from one entry to another
Learning Outcome: 10.2 Discuss the information contained in
the Claim Management dialog box.
Teaching Notes: Show Figure 10.5 in the textbook, the Claim
Management dialog box, and ask students to look over it and
provide feedback. What do they notice? How is it organized?

Is it intuitive?
Explain that there are FIVE navigator buttons, and direct
students’ attention to Figure 10.6 in the text for a visual
connection.
*
10.3 Creating Claims
10-9Claims are created in the Create Claims dialog box of
MNP; to create a claim:Click the Create Claims button in the
Claim Management dialog box; the Create Claims dialog box
will open.Apply the appropriate filters; any box that is not
filled in will default to include all data.Click the Create button
to create the claims.Filter—condition that data must meet to be
selected
Learning Outcome: 10.3 Explain the process of creating claims.
Teaching Notes: When discussing filters, provide concrete
examples of what a filter might be. Discuss filtering by
transaction dates, billing codes, location, etc.
Ask students to discuss the advantages and disadvantages of
using filtering.
*
10.4 Locating Claims
10-10

To locate a claim in MNP:Click the List Only… button in the
Claim Management dialog box; the List Only Claims That
Match dialog box will be displayed.Apply the appropriate
filters.Click the Apply button.The Claim Management dialog
box is displayed, listing only the claims that match the criteria
that were selected.Claims can now be edited, printed, or
transmitted from the Claim Management dialog box.
Learning Outcome: 10.4 Describe how to locate a specific
claim.
Teaching Notes: Ask students to brainstorm some possible
reasons why a claim may need to be relocated (It might need to
be checked for accuracy; it might need to be reviewed before
resubmission if it has been rejected previously; etc.)
Note again that you can apply various filters to make it easier to
search for a claim: chart number, insurance carrier, etc.
*
10.5 Reviewing Claims
10-11Claims should be checked before transmission.Most
PM/EHRs provide a way for billing specialists to review claims
for accuracy.In MNP, this task is accomplished by using the
Edit button in the Claim Management dialog box to load the
Claim dialog box.The more problems that can be spotted and
solved before claims are sent to carriers, the sooner the practice
will receive payment.

Learning Outcome: 10.5 Discuss the purpose of reviewing and
editing claims.
Teaching Notes: It is important to note for students that, when
reviewing a claim in MNP, the baseline information (date of
creation, chart number, claim number, patient name, case
number) CANNOT be edited, only the information contained in
the tabbed sections – carriers, transactions, comments.
*
10.6 Methods of Claim Submission
10-12Three most common methods of transmitting electronic
claims:Direct transmission to the payer—Claims created in the
PM/EHR are sent to the payer’s computer directly via a
connection.Direct data entry—A member of the provider’s staff
manually enters claims into an application on the payer’s
website.Transmission through a clearinghouse—Practices send
their claims to clearinghouses to be edited and then sent to the
payer; this is the method used by most providers.
Learning Outcome: 10.6 Analyze the methods used to submit
electronic claims.
Teaching Notes: Have students debate the merits and
drawbacks of the three methods of claim transmission. Which
one do they think is best? Why? Which would they most like
to employ in their future jobs? Why?
*

10.6 Methods of Claim Submission (Continued)
10-13Companion guide—guide published by a payer that lists
its own set of claim edits and formatting conventionsCrossover
claim—claim billed to Medicare and then submitted to Medicaid
Learning Outcome: 10.6 Analyze the methods used to submit
electronic claims.
Teaching Notes: Discuss with students why each payer seems
to have their own ways of dealing with claim edits and
formatting. If everyone did things the same way, there would
be no need for a companion guide; why is there so much
inconsistency?
Remind students that Medicaid is known as the “payer of last
resort.”
*
10.7 Submitting Claims in Medisoft
10-14
To submit electronic claims in MNP:Select Revenue
Management > Revenue Management… on the Activities menu;
the Revenue Management window opens.Select Claims on the
Process menu.Select an EDI receiver.To perform an edit check,
click Check Claims; when complete, the Edit Status column
displays the status of each claim.To continue with ready-to-send
claims, select Send, select Claims, and select the EDI receiver.

Learning Outcome: 10.7 List the steps required to submit
electronic claims.
Teaching Notes: Explain to students that MNP has a number of
built-in edit functions, such as ANSI, common, and user-defined
edits. More options, like the CCI edits and Medicare policy
edits, are available but require an annual subscription. Ask
students if the annual fee is worth it to have those additional
editing capabilities – why or why not?
When walking through the steps to submit electronic claims, use
the screenshots in the textbook to provide a visual for students
(pages 512-515).
*
10.7 Submitting Claims in Medisoft
Network Professional (Continued)
10-15
To submit electronic claims in MNP (continued):A claim file is
created and a preview report is displayed.If any errors are
identified, the claims must be edited before they can be
transmitted.Click the Send button to send the claim files.
Learning Outcome: 10.7 List the steps required to submit
electronic claims.
*

10.8 Sending Electronic Claim
Attachments
10-16Attachments that accompany electronically transmitted
claims must be referred to in the claim.In MNP, the EDI Report
Area within the Diagnosis tab of the Case dialog box is used to
indicate that there is an attachment and how it will be
transmitted.An attachment control number is required if the
transmission code is anything other than AA.
Learning Outcome: 10.8 Describe how to add attachments to
electronic claims.
Teaching Notes: Ask students why any attachments must be
referenced in the claim itself.
Give a pop quiz of the report type codes to reinforce them with
students.
*
10.9 Claim Adjudication
10-17Adjudication—series of steps that determine whether a
claim should be paidInitial processing—Data elements are
checked by the payer’s front-end claims processing
systems.Automated review—Payers’ computer systems apply
edits that reflect their payment policies.Manual review —Claims
with problems are set aside for further review.Determination—
Payer makes a decision about how to handle a claim.Payment—
If due, payment is sent to the provider.

Learning Outcome: 10.9 Explain the claim determination
process used by health plans.
Teaching Notes: Discuss why there are so many steps taken
before determination of claim payment.
Explain that in the Automated Review step alone, there are TEN
different facets that are evaluated (found on textbook pages
518-519).
*
10.9 Claim Adjudication (Continued)
10-18Suspended—claim status when the payer is developing the
claimDevelopment—process of gathering information to
adjudicate a claimDetermination—payer’s decision about the
benefits due for a claimMedical necessity denial—refusal by a
plan to pay for a procedure that does not meet its medical
necessity criteria
Learning Outcome: 10.9 Explain the claim determination
process used by health plans.
Teaching Notes: See notes on Slide 17. Also provide examples
of various claims and ask student groups to determine what
status their assigned claim might have been given and why.
Choose a variety of claims; if no actual sample claims are
available, create some scenarios that involve each of the key
terms listed here.
*

10.10 Monitoring Claim Status
10-19Practices closely track their accounts receivable using
their PM/EHR.After claims have been accepted for processing
by payers, their status is monitored using the
PM/EHR.Monitoring claims during adjudication requires two
types of information:The amount of time the payer is allowed to
take to respond to the claimHow long the claim has been in
process
Learning Outcome: 10.10 Discuss the use of the PM/EHR to
monitor claims.
Teaching Notes: Note that a practice IS allowed to send an
electronic inquiry at any time to a payer. Direct students’
attention to Table 10.2 in their text, which outlines some Claim
Status Codes that a practice might receive in reference to a
query.
Ask students what time frame they think might be fair for claim
payment/turnaround. Compare their responses to actual wait
times and use that as entry into a discussion on why payments
tend to take a long period of time.
*
(Continued)
10-20Prompt payment laws—state laws that mandate a time
period within which clean claims must be paidClaim turnaround

time—time period in which a health plan must process a
claimAging—classification of accounts receivable by length of
timeInsurance aging report—report that lists how long a payer
has taken to respond to insurance claims
monitor claims.
Teaching Notes: Most of the key terms on this slide and the
following slide might have already been covered at the
beginning of this PowerPoint. If so, refresh students’ memories
and tie the terms into the section being discussed. If not, use
this time to showcase and explain the terms using examples to
strengthen understanding.
Give students an assignment to research prompt payment laws –
are they the same in every state? Are they similar? Are there
any unique variations? Why do students think this is the case?
*
(Continued)
10-21HIPAA X12 276/277 Health Care Claim Status
Inquiry/Response—electronic format used to ask payers about
claimsClaim status category codes—used to report the status
group for a claimPending—claim status in which the payer is
waiting for information before making a payment decisionClaim
status codes—used to provide a detailed answer to a claim
status inquiry

monitor claims.
When discussing claim status codes, call out various codes and
ask students what response they think a practice would have
upon receiving that code.
*

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