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Section 1
Capture charges and prepare professional claims
Preview
Preview: 4. Billing and Reimbursement (33 of 100 scored items)
Preview includes- 4 of 7 lesson topics
- 1 overview segment
- 3 core concepts
- 2 exam tips
Lesson Topics
- Diagnosis Code Selection
- Procedure Code Selection
- Modifier Application
- Encounter Documentation Review
Overview
This objective focuses on the accurate capture of charges and the preparation of professional claims, aligning with documentation and payer guidelines.
Core Concepts
- Charge reconciliation must be performed by comparing charges to supporting documentation.
- All required fields within CMS-1500 and 837P claim forms must be validated.
- Modifiers accurately reflect the services rendered and must be supported by the documentation.
Exam Tips
- Carefully review the encounter documentation for all relevant codes, modifiers, and charges.
- Pay close attention to payer-specific instructions and data format requirements.
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Section 2
Abstract supported information from clinical documentation
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Section 3
Verify insurance information and required documentation
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Section 4
Integrate revenue-cycle phases and payer requirements
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Section 5
Transmit and scrub claims using the correct workflow
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Section 6
Select the appropriate diagnosis or procedure code system
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Section 7
Determine eligibility, benefits, and patient responsibility
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Section 8
Post and reconcile payments and adjustments
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Section 9
Apply specificity, sequencing, conventions, and modifiers
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Section 10
Communicate accurately with revenue-cycle stakeholders
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Section 11
Resolve rejections, denials, appeals, and aging accounts
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Section 12
Resolve documentation and medical-necessity concerns
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Section 13
Coordinate benefits and claim filing order
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Section 14
Protect PHI and manage permitted disclosure
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Section 15
Distinguish payer types and authorization requirements
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Section 16
Apply compliance, audit, fraud, and abuse safeguards
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