Full Download pdf of (eBook PDF) Understanding Health Insurance: A Guide to Billing and Reimbursement 15th Edition all chapter

(eBook PDF) Understanding Health
Insurance: A Guide to Billing and

Reimbursement 15th Edition
Go to download the full and correct content document:
https://ebooksecure.com/product/ebook-pdf-understanding-health-insurance-a-guide-t
o-billing-and-reimbursement-15th-edition/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...
(eBook PDF) Understanding Health Insurance: A Guide to

Billing and Reimbursement 14th Edition
http://ebooksecure.com/product/ebook-pdf-understanding-health-
insurance-a-guide-to-billing-and-reimbursement-14th-edition/
Understanding Health Insurance: A Guide to Billing and

Reimbursement - 2022 Edition 17th Edition - eBook PDF
https://ebooksecure.com/download/understanding-health-insurance-
a-guide-to-billing-and-reimbursement-ebook-pdf/
(eBook PDF) Health Insurance and Managed Care 5th

Edition
http://ebooksecure.com/product/ebook-pdf-health-insurance-and-
managed-care-5th-edition/
(eBook PDF) Understanding Rhetoric: A Graphic Guide to

Writing 2nd Edition
http://ebooksecure.com/product/ebook-pdf-understanding-rhetoric-
a-graphic-guide-to-writing-2nd-edition/
(eBook PDF) Understanding Social Statistics: A
Student's Guide to Navigating the Maze
http://ebooksecure.com/product/ebook-pdf-understanding-social-
statistics-a-students-guide-to-navigating-the-maze/
(eBook PDF) Applied Insurance Analytics: A Framework
http://ebooksecure.com/product/ebook-pdf-applied-insurance-
analytics-a-framework/
(eBook PDF) Understanding Communication Theory: A

Beginner's Guide
http://ebooksecure.com/product/ebook-pdf-understanding-
communication-theory-a-beginners-guide/
(eBook PDF) Understanding Deviance: A Guide to the

Sociology of Deviance and Rule Breaking, Second
Canadian Edition
http://ebooksecure.com/product/ebook-pdf-understanding-deviance-
a-guide-to-the-sociology-of-deviance-and-rule-breaking-second-
canadian-edition/
(eBook PDF) Understanding Business Valuation: A

Practical Guide To Valuing Small To Medium Sized
Businesses 5th Edition
http://ebooksecure.com/product/ebook-pdf-understanding-business-
valuation-a-practical-guide-to-valuing-small-to-medium-sized-
businesses-5th-edition/
vi Table of Contents
Children’s Health Insurance Case Management. . . . . . . . . . . . . 569 Merchant Marine Act

Program. . . . . . . . . . . . . . . . . . . . 536 Program Integrity Office . . . . . . . . 570 (Jones Act). . . . . . . . . . . . . . . . . . 601
Programs of All-inclusive Care CHAMPVA . . . . . . . . . . . . . . . . . . 570 State Workers’ Compensation
for the Elderly (PACE) . . . . . . . . . 536 Programs. . . . . . . . . . . . . . . . . . . 601
Eligibility for CHAMPVA. . . . . . . . . 570
Spousal Impoverishment Eligibility for Workers’
Veterans Choice Program . . . . . . . 571
Protection . . . . . . . . . . . . . . . . . . 537 Compensation Coverage. . . . . . . 601
TRICARE Coverage. . . . . . . . . . . 571
Confirming Medicaid Eligibility . . . 538 Classification and Billing
Medicaid Coverage. . . . . . . . . . . 538 TRICARE Options. . . . . . . . . . . . . . 571
of Workers’ Compensation
TRICARE Special Programs . . . . . 576 Cases. . . . . . . . . . . . . . . . . . . . . . 602
Services for Categorically Needy
Eligibility Groups. . . . . . . . . . . . . 539 Supplemental Health Care
Classification of Workers’
Programs. . . . . . . . . . . . . . . . . . . 577
Services for Medically Needy Compensation Cases . . . . . . . . . 602
Eligibility Groups. . . . . . . . . . . . . 539 TRICARE Billing Notes . . . . . . . . 577
Billing Workers’
Preauthorized Services . . . . . . . . . 540 TRICARE Contractors . . . . . . . . . . 578 Compensation Cases . . . . . . . . . 603
Medicaid Reimbursement. . . . . . 540 Claim Used. . . . . . . . . . . . . . . . . . . 578 Workers’ Compensation
Medicare-Medicaid Relationship. . .541 Filing Deadline . . . . . . . . . . . . . . . . 578 and Managed Care . . . . . . . . . . . 603
Medicaid as a Secondary Allowable Fee Determination. . . . . 578 Forms and Reports. . . . . . . . . . . 604
Payer. . . . . . . . . . . . . . . . . . . . . . 541 Deductibles . . . . . . . . . . . . . . . . . . 578
First Report of Injury Form. . . . . . . 604
Participating Providers . . . . . . . . . 541 Confirmation of Eligibility. . . . . . . . 578
Appeals and Adjudication. . . . . . 607
Medicaid and Managed Care . . . . 542 Accepting Assignment. . . . . . . . . . 580
TRICARE Limiting Charges . . . . . . 580 Fraud and Abuse. . . . . . . . . . . . . 609
Medicaid Eligibility
Verification System. . . . . . . . . . . 542 Special Handling . . . . . . . . . . . . . . 580 Workers’ Compensation
Medicaid Remittance Advice. . . . . 543 Military Time. . . . . . . . . . . . . . . . . . 580 Billing Notes . . . . . . . . . . . . . . . . 609
Utilization Review. . . . . . . . . . . . . . 544 TRICARE Claims Eligibility. . . . . . . . . . . . . . . . . . . . . 609
Medical Necessity. . . . . . . . . . . . . 544 Instructions. . . . . . . . . . . . . . . . . 581 Identification Card. . . . . . . . . . . . . 609
Medicaid Billing Notes . . . . . . . . 545 TRICARE as Secondary Fiscal Agent. . . . . . . . . . . . . . . . . . 609
Fiscal Agent. . . . . . . . . . . . . . . . . . 545 Payer Claims Instructions. . . . . 589 Underwriter . . . . . . . . . . . . . . . . . . 610
Timely Filing Deadline . . . . . . . . . . 545 TRICARE and Supplemental Forms and Claim Used . . . . . . . . . 610
Accept Assignment . . . . . . . . . . . . 545 Coverage Claims Filing Deadline . . . . . . . . . . . . . . . . 610
Instructions. . . . . . . . . . . . . . . . . 592 Deductible . . . . . . . . . . . . . . . . . . . 610
Deductibles . . . . . . . . . . . . . . . . . . 545
Copayments. . . . . . . . . . . . . . . . . . 545 Copayment. . . . . . . . . . . . . . . . . . . 610
Inpatient Benefits. . . . . . . . . . . . . . 545 Chapter 17: Workers’ Premium. . . . . . . . . . . . . . . . . . . . . 611
Major Medical/Accidental Compensation 597 Approved Fee Basis. . . . . . . . . . . . 611
Injury Coverage. . . . . . . . . . . . . . 545 Federal and State Workers’ Accept Assignment . . . . . . . . . . . . 611
Medicaid Eligibility. . . . . . . . . . . . . 546 Compensation Programs . . . . . . 598 Special Handling . . . . . . . . . . . . . . 611
Medicaid Cards . . . . . . . . . . . . . . . 546 Federal Workers’ Private Payer Mistakenly Billed. . . 611
Remittance Advice. . . . . . . . . . . . . 546 Compensation Programs . . . . . . 598 Workers’ Compensation
Medicaid Claims Coal Mine Workers’ Claims Instructions. . . . . . . . . . . 611
Instructions. . . . . . . . . . . . . . . . . 546 Compensation Program . . . . . . . 599
Medicaid as Secondary Energy Employees Occupational
Payer Claims Instructions. . . . . 553
Appendix I: Forms 622
Illness Compensation
Medicaid Mother/Baby Program. . . . . . . . . . . . . . . . . . . . 599 E/M Codebuilder. . . . . . . . . . . . . 625
Claims Instructions. . . . . . . . . . . 556 Federal Employees’ Appendix II: Dental Claims
CHIP Claims Instructions. . . . . . 559 Compensation Program . . . . . . . 599 Processing 629
Longshore and Harbor
Workers’ Compensation Dental Claims Processing. . . . . . 629
Chapter 16: TRICARE 565 Program. . . . . . . . . . . . . . . . . . . . 599 Current Dental Terminology
TRICARE History. . . . . . . . . . . . . 566 Employees’ Compensation (CDT). . . . . . . . . . . . . . . . . . . . . . 629
TRICARE . . . . . . . . . . . . . . . . . . . . 566 Appeals Board. . . . . . . . . . . . . . . 600 CDT Coding Practice . . . . . . . . . 630
Transitional Health Care Mine Safety and Health
Options . . . . . . . . . . . . . . . . . . . . 568 Administration. . . . . . . . . . . . . . . 600 Appendix III: Abbreviations 632
TRICARE Administration. . . . . . . 568 Occupational Safety and Bibliography 636
TRICARE Service Centers. . . . . . . 569 Health Administration . . . . . . . . . 600
Glossary 638
Military Treatment Facilities. . . . . . 569 Federal Employment
Liability Act . . . . . . . . . . . . . . . . . 600 Index 665
Copyright 2021 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
PREFACE
Introduction
Accurate processing of health insurance claims has become more exacting and rigorous as health insurance plan
options have rapidly expanded. These changes, combined with modifications in state and federal regulations
affecting the health insurance industry, are a constant challenge to health care personnel. Those responsible for
processing health insurance claims require thorough instruction in all aspects of medical insurance, including plan
options, payer requirements, state and federal regulations, abstracting of source documents, accurate completion
of claims, and coding of diagnoses and procedures/services. Understanding Health Insurance provides the
required information in a clear and comprehensive manner.
The text was designed and revised to support core learning objectives for the health insurance specialist.
Chapter objectives, content, and assessments are all aligned to ensure students learn and practice the concepts
and skills they’ll need on the job. Student learning is supported through chapter outlines and measurable
objectives identified at the beginning of each chapter, as well as chapter headings and assessments that clearly
map to those chapter outlines and objectives.
Special attention was focused on selecting appropriate Bloom’s taxonomy levels for each chapter objective
along with mapping assessment items (e.g., exercises, exam questions) to each objective. In addition, the 185 CHAPTER 6: ICD-10-CM Coding
Workbook to Accompany Understanding Health Insurance containsCross-References assignments that map to higher Bloom’s
taxonomy levels to provide students with more advanced activity-based learning experiences such as assignment
The ICD-10-CM index includes cross-references, which instruct the coder to refer to another entry in the index
(e.g., see, see also, see condition) or to the tabular list (e.g., see category) to assign the correct code.
of APCs and DRGs, and assigning codes to actual patient records. The see instruction after a main term directs the coder to refer to another term in the ICD-10-CM index to
●
locate the code. The coder must go to the referenced main term to locate the correct code.
● The see also instruction is located after a main term or subterm in the ICD-10-CM index and directs the
coder to another main term (or subterm) that may provide additional useful index entries. The see also
instruction does not have to be followed if the original main term (or subterm) provides the correct code.
● The see category instruction directs the coder to the ICD-10-CM tabular list, where a code can be
selected from the options provided there.
● The see condition instruction directs the coder to the main term for a condition, found in the ICD-10-CM
disease index.
EXAMPLE 1: Locate the main term “Laceration” and subterm “blood vessel” in the ICD-10-CM index. Notice that a
CHAPTER cross-reference directs you to “see Injury, blood vessel,” a different location in the index where the code can be found.
EXAMPLE 2: The see also instruction is optional if the correct code can be located below the main term (e.g., ICD-
6 ICD-10-CM Coding 10-CM index entry “Laceration, lower back —see Laceration, back, lower”). If the correct code cannot be located, the see
also cross-reference directs the coder to a different location in the index where the code can be found.
EXAMPLE 3: Locate the main term “Pyelitis,” subterm “with,” and second qualifier “calculus” in the ICD-10-CM index.
Notice that a cross-reference directs you to see category N20. To assign the correct code, review category N20 in the
tabular list to select the appropriate fourth digit.
EXAMPLE 4: Locate the main term “Accidental” in the ICD-10-CM index, and notice that a cross-reference directs you
Chapter Outline to see condition, which means the patient record needs to be reviewed to determine the exact condition (e.g., fracture).
General Equivalence Mappings ICD-10-CM Index and Tabular List

Overview of ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting
ICD-10-CM Coding Conventions
Exercise 6.3 – ICD-10-CM Coding Conventions
Instructions: Assign ICD-10-CM codes to each diagnostic statement, interpreting coding
Chapter Objectives conventions.
Upon successful completion of this chapter, you should be able to: 1. Acariasis infestation
1. Define key terms related to ICD-10-CM coding. 2. Costen’s complex
2. Use general equivalence mappings to identify ICD-10-CM codes for equivalent ICD-9-CM 3. ST elevation myocardial infarction, anterior wall,
codes. involving left main coronary artery
3. Describe the use and characteristics of the ICD-10-CM and ICD-10-PCS coding systems.
4. Malaria with hepatitis
4. Interpret ICD-10-CM coding conventions for accurate code assignment.
5. Acute lymphangitis
5. Assign ICD-10-CM codes to diseases.
6. Interpret official guidelines for ICD-10-CM coding and reporting. 6. Absence of menstruation
7. Arterial atheroembolism
Key Terms 8. Cataract in hypoparathyroidism
9. Acromegaly
adverse effect encoder code first underlying Excludes2 note
disease 10. Cirrhosis due to Wilson’s disease
benign encounter in
carcinoma (Ca) in situ essential modifier code first underlying in diseases classified 11. Keratoconjunctivitis in exanthema
disease, such as: elsewhere
comorbidity evidence-based coding 12. Appendicitis with perforation
code, if applicable, any includes note
complication first-listed diagnosis
causal condition first
computer-aided coding general equivalence manifestation
colon
(CAC) mapping (GEM) NEC (not elsewhere
due to classifiable)
computer-assisted iatrogenic illness
coding (CAC) eponym NOS (not otherwise
ICD-10-CM coding
contiguous sites conventions etiology and specified)
and manifestation rules other and other specified
Cooperating Parties for
ICD-10-CM/PCS brackets Excludes1 note code
vii
viii Preface
Objectives
The objectives of this text are to:
1. Introduce information about major insurance programs and federal health care legislation.
2. Provide a basic knowledge of national diagnosis and procedure coding systems.
3. Explain the impact of coding compliance and clinical documentation improvement (CDI) on health care
settings.
4. Simplify the process of completing claims.
This text is designed to be used by college and vocational school programs to train medical assistants,
medical insurance specialists, coding and reimbursement specialists, and health information technicians. It can
also be used as an in-service training tool for new medical office personnel and independent billing services, or
individually by claims processors in the health care field who want to develop or enhance their skills.
Features of the Text

Major features of this text include:
●● Key terms, section headings, and learning objectives at the beginning of each chapter help organize the
material. They can be used as a self-test for checking comprehension and mastery of chapter content.
Boldfaced key terms appear throughout each chapter to help learners master the technical vocabulary
associated with claims processing.
●● CPT, HCPCS level II, and ICD-10-CM coverage presents the latest coding information, numerous
examples, and skill-building exercises. Detailed content prepares students for changes they will encounter
on the job.
●● CMS-1500 claims appear throughout the text to provide valuable practice with manual claims completion,
and SimClaim™ practice software, available online within MindTap, presents the electronic version. The
UB-04 claim appears in Chapter 11 with its claims completion instructions.
●● Coding exercises are located throughout textbook Chapters 6 through 8 and 10, and claims completion
exercises are located throughout Chapters 11 through 17. Answers to exercises are available from your
instructor.
●● Numerous examples are provided in each chapter to illustrate the correct application of rules and guidelines.
●● Notes clarify chapter content, focusing the student’s attention on important concepts. Coding Tips provide
practical suggestions for mastering the use of the CPT, HCPCS level II, and ICD-10-CM coding manuals.
HIPAA Alerts draw attention to the impact of this legislation on privacy and security requirements for patient
health information.
●● End-of-chapter reviews reinforce learning and are in multiple-choice format with a coding completion
fill-in-the-blank format available for coding chapters. Answers to chapter reviews are available from your
instructor.
●● MindTap is a fully online, interactive learning platform that combines readings, multimedia activities, and
assessments into a singular learning path, elevating learning by providing real-world application to better
engage students. MindTap can be accessed at http://login.cengage.com.
●● SimClaimTM, the practice software available online within MindTap, contains case studies that
include billing data and patient histories, and allow for data entry on CMS-1500 claims, with immediate
feedback. Instructions for using SimClaimTM are located at the end of this Preface.
Preface ix
New to this Edition

●● Chapter 1: New “Independent Contractor and Employer Liability” and “Professional Associations and
Credentials” headings were created for existing content. Chapter objectives were revised to align with
existing and new headings.
●● Chapter 2: Content about the Quality Payment Program (QPP) was updated, and a new Merit-Based
Incentive Payment System (MIPS) assignment was created for the Workbook to Accompany Understanding
Health Insurance.
●● Chapter 3: Content clarifying the 2006 CURES Act, Healthcare Effectiveness Data and Information Set
(HEDIS) is now located below the “National Committee for Quality Assurance (NCQA)” heading, and
multiple choice questions were added to the chapter review.
●● Chapter 4: Content about encounter forms and chargemasters was expanded, including the addition of an
example. The “Insurance Claim Cycle” heading was revised to delete the word “Revenue.”
●● Chapter 5: Content about CMS transmittals was revised and content about CMS quarterly provider updates
and CMS Internet-only manuals was added. HIPAA content was relocated to later in the chapter so that it
appears prior to content about HIPAA administrative simplification.
●● Chapter 6: ICD-10-CM guidelines and codes were updated. Content about ICD-10-PCS guidelines,
examples, and coding practice was newly created, and it is available at the Student Companion Site
(with code answers available at the Instructor Companion Site).
●● Chapter 7: CPT coding guidelines and codes were updated.
●● Chapter 8: HCPCS level II guidelines and codes were updated.
●● Chapter 9: Content about data mangement and the new Hospice Payment System were added, and
content about resource utilization groups (RUGs) was replaced by the new patient driving payment method
(PDPM) system.
●● Chapter 10: ICD-10-CM, HCPCS level II, and CPT codes were updated.
●● Chapters 11 to 17: ICD-10-CM, HCPCS level II, and CPT codes were updated. Insurance claims completion
instructions and the CMS-1500 claim were revised according to the latest industry guidelines and standards.
●● SimClaimTM practice software available within MindTap, includes updated ICD-10-CM, HCPCS level II, and
CPT Codes.
Organization of This Textbook

●● Chapter outlines, key terms, objectives, chapter exercises, end-of-chapter summaries, and reviews facilitate
student learning.
●● Chapter 1, Health Insurance Specialist Career, contains an easy-to-read table that delineates training
requirements for health insurance specialists.
●● Chapter 2, Introduction to Health Insurance, contains content about health care insurance developments.
A table containing the history of significant health insurance legislation in date order simplifies laws and
regulations implemented. Meaningful use content remains in the chapter to serve as background for
content about the new quality payment program (e.g., Advanced APMs, eCQMs, MIPS).
●● Chapter 3, Managed Health Care, contains content about managed care plans, consumer-directed health
plans, health savings accounts, and flexible spending accounts. A table contains the history of significant
managed health care legislation in date order to organize the progression of laws and regulations.
●● Chapter 4, Revenue Cycle Management, contains content about managing the revenue cycle claims
processing steps, and the denials/appeals process.
x Preface
●● Chapter 5, Legal and Regulatory Issues, emphasizes confidentiality of patient information, retention of
patient information and health insurance records, the Federal False Claims Act, the Health Insurance
Portability and Accountability Act of 1996, and federal laws and events that affect health care.
●● Chapter 6, ICD-10-CM Coding, contains coding conventions and coding guidelines with examples.
An overview about ICD-10-PCS is also provided, and additional content can be found at the Student
Companion Site at http://login.cengage.com. The coding conventions for the ICD-10-CM Index to
Disease and Injuries and ICD-10-CM Tabular List of Diseases and Injuries are clearly explained and include
examples. In addition, examples of coding manual entries are included.
The chapter review includes coding statements, which are organized according to the ICD-10-CM chapters.
NOTE:
The ICD-10-CM chapter is sequenced before the CPT and HCPCS level II chapters in this textbook because diagnosis codes are
reported for medical necessity (to justify procedures and/or services provided).
●● Chapter 7, CPT Coding, follows the organization of CPT sections. The chapter review includes coding
statements organized by CPT section.
●● Chapter 8, HCPCS Level II Coding, contains content about the development and use of the HCPCS level II coding
system and its modifiers. The chapter review includes coding statements organized by HCPCS level II section.
●● Chapter 9, CMS Reimbursement Methodologies, contains information about reimbursement systems
implemented since 1983 (including the Medicare physician fee schedule).
●● Chapter 10, Coding Compliance Programs, Clinical Documentation Improvement, and Coding for Medical
Necessity, contains information about the components of an effective coding compliance plan, and content
about clinical documentation improvement and coding for medical necessity. Coding exercises (e.g., case
scenarios, patient reports) are also included.
●● Chapter 11, CMS-1500 and UB-04 Claims, contains general instructions that are followed when entering
data on the CMS-1500 claim, a discussion of common errors made on claims, guidelines for maintaining
the practice’s insurance claim files, and the processing of assigned claims. UB-04 claims instructions are
included, along with a case study.
●● Claims completion instructions in Chapters 12 through 17 are located in an easy-to-read table format, and
students can follow along with completion of the John Q. Public claims in each chapter (and complete the Mary
Sue Patient claims as homework) by copying the blank CMS-1500 claim in Appendix I or using MindTap.
Resources for the Instructor

Spend less time planning and more time teaching with Cengage Learning’s Instructor Resources to Accompany
the 2020 Edition of Understanding Health Insurance. As an instructor, you will find these resources offer
invaluable assistance anywhere, at any time.
All instructor resources can be accessed by going to http://login.cengage.com to create a unique user login.
Contact your sales representative for more information. Online instructor resources at the Instructor Companion
Website are password-protected and include the following:
Instructor’s Manual
In Adobe’s PDF format, the Instructor’s Manual contains the following sections:
●● Section I – Preparing Your Course
●● Section II – Answer Keys to Textbook Chapter Exercises and Reviews
●● Section III – Answer Keys to SimClaimTM Case Studies
Preface xi
●● Section IV – Instructor’s Materials

●● Section V – Answer Keys to Workbook Chapter Assignments
●● Section VI – Answer Key to Mock CMRS Exam
●● Section VII – Answer Key to Mock CPC-P Exam
●● Section VIII – Answer Key to Mock CPB Exam
Test Bank
The computerized test bank in Cognero® makes generating tests and quizzes a snap. Test banks can also be
downloaded using Respondus® software. With approximately 1,500 questions, you can create customized
assessments for your students with the click of a button.
Slide Presentations
Customizable instructor support slide presentations in Microsoft’s PowerPoint® focus on key points for
each chapter.
Conversion Guides
Conversion grids map the Fourteenth Edition to the 2020 Edition, and to competitive titles.
SimClaimTM Software
SimClaimTM, interactive CMS-1500 claims completion software available within MindTap, includes 40 updated
coding case studies.
Updates and Resources

Revisions to the textbook, workbook, Instructor’s Manual, SimClaimTM, and test bank due to coding updates
are posted. The Instructor Site also includes access to all student supplements, as well as additional
textbook content.
Resources for the Student

Student Workbook
(ISBN 978-0-357-37865-6)
The Workbook follows the text’s chapter organization and contains
application-based assignments. Each chapter assignment includes
a list of objectives, an overview of content relating to the assignment,
and instructions for completing the assignment. Other components
may be present depending on the assignment.
Each chapter contains review questions, in multiple-choice
format, to emulate credentialing exam questions. In Chapters 11
through 17, additional case studies allow more practice in completing
the CMS-1500 claim. Appendix A contains a mock CMRS exam;
Appendix B contains a mock CPC-P exam; and Appendix C contains
a mock CPB exam.
xii Preface
Student Companion Site

Additional student resources can be found online at http://login.cengage.com. Student resources include:
●● CMS-1500 and UB-04 claims (blank fill-in forms), additional content related to textbook chapters, and
SimClaimTM Case Studies
●● CMS Evaluation and management services guidance document
●● Revisions to the textbook and workbook due to coding updates
●● E/M CodeBuilder, including a tutorial for its use (that can be printed to use as a worksheet)
●● Final test for AAPC CEU approval
MindTap
Green’s Understanding Health Insurance, 2020 Edition on MindTap is the first of its kind in an entirely new
category: the Personal Learning Experience (PLE). This personalized program of digital products and services
uses interactivity and customization to engage students, while offering instructors a wide range of choice in
content, platforms, devices, and learning tools. MindTap is device agnostic, meaning that it will work with any
platform or learning management system and will be accessible anytime, anywhere: on desktops, laptops,
tablets, mobile phones, and other Internet-enabled devices.
MindTap includes:
●● An interactive eBook with highlighting and note-taking capability
●● Flashcards for practicing chapter terms
●● Computer-graded activities and exercises
Self-check and application activities, integrated with the eBook
Case studies with videos
●● Easy submission tools for instructor-graded exercises
ISBNs: 978-0-357-37869-4 (electronic access code); 978-0-357-37870-0 (printed access card)
ABOUT THE AUTHOR
Michelle A. Green, MPS, RHIA, FAHIMA, CPC, has been a

college professor since 1984. She taught traditional classroom-
based courses until 2000 at Alfred State College, when she
transitioned all of the health information technology and coding/
reimbursement specialist courses to an Internet-based format
and continued teaching full-time online until 2016. Upon
relocating to Syracuse, New York, she began teaching for
the health information technology program at Mohawk Valley
Community College (MVCC), Utica, New York. Michelle A.
Green’s teaching responsibilities include alternate care health
information management, health data and quality management,
health information management, insurance and reimbursement,
legal aspects of health information management, pathophysiology
and pharmacology, revenue cycle management, and ICD-10-CM,
ICD-10-PCS, CPT, and HCPCS level II coding courses. Prior to
1984, she worked as a director of health information management
at two acute care hospitals in the Tampa Bay, Florida, area. Both
positions required her to assign codes to inpatient cases. Upon
becoming employed as a college professor, she routinely spent
semester breaks coding for a number of health care facilities so
that she could further develop her inpatient and outpatient coding skills.
xiii
REVIEWERS
Special thanks are extended to the reviewers, Bridgette Stasher-Booker

technical reviewers, and supplement authors who Alabama State University
provided recommendations and suggestions for
improvement throughout the development of the text. Lisa Turner
Their experience and knowledge have been a valuable Southern Union State Community College
resource for the author.
Justina Buck Technical Reviewers

University of Arkansas–Fort Smith
Marsha Diamond, CPC, COC, CCS, CPMA,
AAPC Fellow
Priscilla W. Fisher
Instructor
Ogeechee Technical College
City College
Altamonte Springs, Florida
Ellen Horne
and
Wake Technical Community College Manager
Coding/Compliance, Physician/Outpatient Services
Donna Sue Shellman Medical Audit Resource Services, Inc.
Gaston College Orlando, Florida
xiv
ACKNOWLEDGMENTS
In memory of my son, Eric, who always kept me “on task” by asking, “How much did you get finished in the
chapter today, Mom?” Thank you for truly understanding my need to pursue my passion for teaching and writing.
You always proudly introduced me as your mom, the teacher and writer. You remain forever in my heart, Eric.
A special thank you to my brother, Dave Bartholomew, for his encouragement and support. You are my rock!
To my students, located throughout the world! You always ask me the toughest questions, and you also make
me want to find the answers. You are such wonderful critical thinkers!
To my technical reviewer, Marsha Diamond, thank you for your incredible attention to detail and wonderful
knowledge about all things coding and reimbursement!
To my learning designer, Kaitlin Schlict, thank you for patiently walking me through crucial learning design
methods!
To my senior content manager, Kara DiCaterino, I truly appreciate every single thing you do!
To my mom, Alice B. Bartholomew, for writing real-life case studies for my textbooks and having originally
helped me select a health care career. Your guidance is so appreciated!
Special appreciation is expressed to Optum Publishing Group for granting permission to reprint selected
tables and pages from:
●● CPT Professional
●● HCPCS Level II Professional
●● ICD-10-CM Professional
●● ICD-10-PCS Professional
Feedback
Contact the author at michelle.ann.green@gmail.com with questions, suggestions, or comments about the text
or supplements.
xv
Insuranc
Specialis e CHAPTE
R
t Career
1
HOW TO USE THIS TEXT
Chapter
Outline
Health In
surance O
Career O verview
ppor tunitie
Education s Independe
and Traini nt Contrac
Job Resp ng Professio tor and E
onsibilitie nalism mployer Li
s ability
Professio
nal Assoc
Objectives and Key Terms Chapter iations an
Objectiv d Credent
ials
The Objectives section lists the outcomes Upon su es
c cessful c
expected of the learner after a careful study of the 1. Define mpletion o
key terms of this ch
related to apter, yo
chapter. Review the Objectives before reading the 2. Briefly the health u should
summariz
e he in su ra nc be able to
3. Identif
y career op
alth insura
nc
e specialis
t career. :
chapter content. When you complete the chapter, 4. List th por tunitie
e claims
processin
e educatio s available g and the pa
read the Objectives again to see if you can say for n and trai for health rties invo
5. Descr ning requ insurance lved.
ibe the jo irements specialists
6. Differen b respon of a health .
each one, “Yes, I can do that.” If you cannot, go tiate amon
sibilities of
a health in insurance
7. Explain g types of surance sp specialist.
2
back toCHAP
the appropriate
TER 1: Health Insura nce
content and reread it. the role of insurance ecialist.
Specia list Caree r
8. Identif workplace purchased
y coding p rofessionalis by co ntractors an
and reimb m for a he d employe
Key Terms represent new vocabulary in
International
96 CHAP TER 4: Reve nue medical assistant
ursement
professio alth insura rs.
nce spec
Key Term
Classification Cycle Mana geme nt professionalism nal associ
of scope of practice ialist.
each chapter. Each term is highlighted in color in medical malpractice ations an
Diseases, 10th
Reviims sion, Proc edural
insurance
property insurance
s
workers’ compensation d cred entials of
fered.
the chapter, is used in context, and is defined on reimbursement insurance A APC
Cla
Codi System medical necessity
A claing
Attach ments
ms specialist
(ICD-10-Patta CS)
chment is a set of supp
ortin
first usage. A complete definition of each term
or patient enco
inter nship
unter. Claims attachm
national code s g documentation or infor
ent information can be
remittance advic mation e asso
(rem ciate
it)
American
d with a heal Associatio
bonding
insurance
claim or paper-based claimprofessional liabil
forms. Claims atta ity found in the remarks of Medical th care n
claim business errors an
resp or
appears in the Glossary at the end of the text.
● Medical
insurance chments are used for: onde at supe rior
CHAP TER 1: Health Insura A)
note
(A A
s
M
field s A ss
of an elec istatron
nt s ic insurance
liability
health insu
d omission
insurance s
evaluation for payment nce Specia list Caree r
A merican H 7 rance
the●abilit Pasty paym to think entcritic
auditally. ea C en te rs specialist et hi cs
or revie
The w American Heritage Conc CHAP TER 4: Reven ue Cycle lth for Medic
or ●good ise Dictionar y defines ethic Informatio Mana geme nt 73 and Med are
Quacond lity con uct,troland to ensurulesrethat govern the conduct of mem s as the princ n iples of Healthca
icaid Ser explanatio
re Comm
Introduction
Stuannu
EXAMPLE 2: The Departmen ss to care and qua
acce
lity of care bers of a profession. Managemen
t
right
(CMS) Procedur
vices on (EOB)
n of bene
fits
den ally,t but Int veterern ans shi nationwide p
t of Veterans Affairs (VA) provi
des health care services to A ss
almost three
ociation cl ai m System (H
s examin
e Coding
The in
have traditionally not had equit
able (A H million veterans
er CPCS) HCPCS le
caree
An internshi N
1996
r O Trequi
of apEhealt : ringhfits
bene the
insur VAance to ntsdevel acces s to these services. Congress IM A) enac ve l II codes
stude specop aialist
and plan(or
facilit for reimb
ies equit
that ably ursem alloca ted legislation coding hold harm
for profe econ
ssionaeomic l statu acce ptent ting
stude specresou
ntsialist) rcesplace istoa“ensu Am less clausehealth ca
expe rienc prior advato sgradand eligib
ncem ent.n,
uatio ility
Indiv priori
idual ty andsintern
who who areassis
for chall
ment reengin
.that
Stud er
gents
veterone, ic
ans an with
receiwho Mve oppo
have rtunit re provid
accu Claim
rate of the s are
codin regio gsomenskills
oftimes
the
and the unde
ship eligib
rstan ledfor
ts claim
them medi scalproc care essinhave simila ed icsimila
on-th al ries
e-job C ur independ er
Introduction
bene fit from , delaythe
Unite
have ed
d State
or rejec
s in obta ining gpermand r acces
billing B s
regul
to re nt ent contra he
deter mina the oppo thisrtunit y to abilit in ted
particy ipate which beca
to succ such
use essfuthe
veter payer
llyans resid
need anent emp illingloym suchation
Ass care
s, poss
ent. regaress
Facili dless Proced ctoralth inform
alse.”
Terminolog ural
dem onstr Reso urce tion.
Alloc Ination situa tion, der is in and impro appeve the to obtai
unde In respo n a copy
rpaid nse, thepatie
of
or ation oc ia tion ties Internatio ation
comp doculeteate internwork place
ships (VERA
profe
obta )ssionthe provi
resou rce alloca
alism notifimoni
tion ed oftoringthe reque form al educ denie VAprocimple
dnt recor
insur ment
ess. dsMfor
(Aance ed theoften
Brevie
claim Veter
w s,priorans nal Classifi technician
adve rtisemservimentces.
ents
ation
VERA from
alloca theted in emp
recor d
resou to loym
justif y ent
the
are at in
the dem intern and. ship A syste st m
revie
facilit
for
w toinform
ofimpromedi ation
ve cal and
equit has
y of an
acces oppo
Quite A ) ,and toEquit
stude maki able
ng who
nts a y (C P T) cation
the site. can some Studtimes ents indic areates theifrequ need rces
forto to regiomedi nalcalVA nece ssity of proce y. The students office repo perso s nnel
rtunit
tothe veteryhelp-
toans’
subm healt
it supph care of Disease
rvisor at embezzle
often indiv healt rt to want ed orting
intervdocu
(VISN
iew
moniment
), which
prior ation
tochan
be
allocaavoid
teed
.acceptance for
resou the pract
rces ired
toicetheir subm
conta idual
hosp as profe
ctsititals with
payer
and
h care
all
ssion
s toclinic of these
reque
netwdures
al arésum
s.stThe
orks,
list
skills
VAofconti
orknow
éCPT . servi
to
nces
theHCPC
and
as perfo
intern
Veterrmed
S ship
ans Integ . Thisrated
supe
intern
delayServi ship
in claim supe
s proce
ce Netw The Introduction provides a 10brief
ssing
orks th Revoverview
s, health insu
rance clai
toring ges in health care placement. While
delive this proc ess nuou sly asses level
sesIIthe code srvithat
effec
sorrequi and resche
supp dule an ision, m
Health Insurance Overv can
the interv iew ry and overs be intim tivene ss of orting
equitableproc acces ess,
s to whicservi h is part of obtaining perm the network allocation proceg,
ces.
eeing idatin
ss students gain experience by
used of the major topics covered inClin
VERA
with the
ical chapter.
Modificatio
iew
and utilize interview techn
reviews résumés and provi
ique services available from
anent employment. Students
their school’s career services office
shou
to provide veterans with
ld research résumé writin
g
(ICD-10-C
M)
n
Most healtMP
EXA h care LE 1: prac CPTtices
des interview tips. (Some
modifiersin theareUnite d State s acce
reported on claims toptprovi
offices even videotape mock
resp
. This office typically
interviews for students.)
The Introduction and the Objectives
someand third they-part areyenter paye ed rsas(e.g., Blue Cros deonsib
clarificatioility for filing healt
n abou h insurance claims, and
Encounter Form and
prov idersmodifiers
N O
to file TE:
on claim
claimss.assis
two-
A heal
digit num s Blue
bers. Providersld) Shie thatand subm goveit supprnme ortinntg prog
t proc edur
rams (e.g., Medservi
es and ces performed, provide a framework for your study of the
or gove rnme nt program
Chapt Chargemaster t the th paye insu
r in ranc
making
requesting reimburseme ent determinations
e paym
claim is the documen documen tation when repo
: tation submitted to a third-partthe
icare) require
rting following
manAlon
●
ythat
prac −22
g with
er (Incr
1 of the
tices
teache patie
ease
have
s studen
Workb
d Proc
tsincre
nt regis
ookedur to Accom
ased
howtratio
al Serv
n,the the
pany
ices)
num
Under
encoéber
standi nt for healt h care servi
ng Health Insurance contains ces prov ided. In the
an assignment entitled “Read past
y paye r
few years,
content.
This
serv ●
e −53
incre asase (Disc
the ontin
isstart
a resu ued
to create a résum andof
unte r emp
cover form loyee
and
letter, and s
charassig
helps gem ned aste to som e aspe y, Set, Get a Job”
ing ltpoin Proc
of moret edur
for med e)patie ntscodi them prepa r (or re char
for a job ge interv ct of
desc claim
riptio n smas proc
prior
Each appr oval
ical havin nggand som e form
patie nt billinof healt h insur
iew. ter,essin
or CDM g. )
The−59 heal th care
(Dist forincttreat g of heal th care anceserv , man
Notes
●
inter nship setti
Proc men talby
ng (e.g.,
edur Serv spec
phys
ice) ialist
ician soffic
and icesy ofand whom proc requ ire
requ
char irem ents is on-th e-job training even thoughital e, docu
hosp men tatio
outp n of post -trea edur es.
of immu gem aste arer notue
uniq met, to paym
its ent it is unpa atienid, t depa rtme tmen nt) t
crearepo rts. If prior
nizations (available from organizat of ion.the The claim is denie and students shou tesld an enco appr oval or
insur
repo ance
rtingplan a phys ongo ing main d. According to BlueisCros expe ct unteto prov r form
and parti of med
cipat
has a hold
e in ical codeharm s for reim less clau ician) and
se (patie poss ibly tena undence rgoof a each preemplo nece s ssar
BlueyShie to ensu ld, ifrean ide proof
denie
orga EXA in MP
s)nizat the
ion’s LE
cont an orien
2:ract,
enco Whe n ar form
the tatio
provi
healt n. In burs addieme tion,ntbeca purp ntoses
is notAltho
use of. the
respugh onsib med le ical
for payin ymen
gs are
what
t phys
thenely ical exam theinatio
Notes appear throughout the text and
accunrate
inforcode
matio n, the facili unte der
orh perfo
care
char prov
rms
gem a ider
proc cann
edur ot focu s on priva code
cy and routi insur ance
upda plan
realiz
asso thatis d
e ciate repo
not rtedserv
all on
insur ty
the will likely requ ire studaster com e mitte
for colle
whic e hctthere
revie thews isfees
no from
CPT the security of patient ted, the
conf identiality), whichices with ance claim
and ,
policsupp ies ortin
cont g es ents to sign a nondisclosuretoagre them or HCPC
ensu patie
reSthat nt.
levelappr II Itcode
isopria
impo rtant
balan
outdce ated billin med g claus ical code e thatis kept
s, prote
reducing
proc edur docu
on file at the college .and
cts patie
ainprov
nts from
men
hold tatio
ided harm n must
less be
This helps elimiclaus
subm
by the internship
es.
itted How
nate (e.g., ever,
the copyposs
eme
man
of ibility
oper
nt
y polic (to
ative
of repo
protect patientto
ies cont
repo
and
rt).
tean
ain
unlis
code
a no
serve to bring important points to your
ted
s are
for copayments, coinsuran the incid ence being of claim billed for amo unts site. rting erron eous or
ce amounts, and deductible s denials. not reimbursed by paye
these conc NOTE:
epts.) In addition, patie nts s). (Cha pter 2 contains more
infor mation about
rs (exce pt attention. The Notes may clarify content,
not parti refer red to nonp artic ipating prov iders (e.g., a
EXA cipat MPL e inE:a The
have HIP
Breac
antic
facilit
h of
ipate
patien
y’sionancill
d. Com
ary
parti
t confid cular
hosp
entiali tyhealt
ital’s cancharg h emas
resultcareter plan)
in termin comm incur
ation ittee
of the signi
conta
internfican
insship,
mem tly highe
bers mean from r out-o f-poc
physician who does refer you to reference material, provide
petit
depa sinform the ket
or expuls ive
rtmen ation costs
from your acade micinsur
tsprogra
(e.g., ance are com
mradio logy,panie pathology, sle are
which failing techn
intern ology than
and. all they of themay
AA
fine- ship course
Ale
costsrequir other and tunin
radioement possib labor Suspe
more background for selected topics, or
rt!
and logy
overa treatm
ll expe ent,ndituand conse quenc atoryg
es. Be sure proc
). A patie edur es
ntabout toyour
is regis redu nsion
process,
Trad
the whicition s regard
electally, claimings attac res.radio
the
this issue.
hme
This logist
cost- cann redu ot locat
ction e an cam paign
appro priate force
to ask tered ce
acade formic adm
hosp inistr
ital outpa
progra m’sative tient
ronic
h in charg turn emas
incre ter.
ases Shethents cont ainin g med ical docu CPT s close
code (or r scru
descr tiny
iptionof ) forthe
repo rted on claim contatime cts the
and charg
effor emas
t men tatio n that theentir new eservi
claim ce son
loweDurin
opera
according to
electroni
torthe
g the c
annoinsur
intern
attac
unceance s
ship,
hme
awere
“charpoliccopi
gemaed yster from
filing patie
statrequ meet nt
ing”
irem reco in
ents. rds
the
med ter ical
comm
and logy
radio
Poor mail
prac itteetices
ed to
chairmust
paye
supp
person,devo
rs.
orte
whodtehas proc
tothe edur
billin hosp esand
g andswitc
ital servhboa
filing ices
claimemphasize exceptions to rules.
rd s
r reim burseme
Availa ble mem nt rates nts stude
with ntselec are expe
troni c claim cteds to repo
atten depation rtmen to claim t. Effec tive
s requirem 200ents 6, prov iders
the intern
med shipdocu
ical on men a partic
bers oftothe the comm prac tices
ittee gatheand or
incresend rtelec
to worktroni on
cnses
attac time. Students will resu subm
lt in it
repre
A numb senta oftive
erdesig selec tatio ular
ts an n to daysupp (orortwho claim arrive
s subm
r to
late)
talk
shou
ased
with the experadio logist . hme
abounts t theinnew resp who onse cann tothe ot partic
requ ests ipate in
whoe healt h care appro priate itted ld
(e.g. conta ct servi ce, for
Icons
ver is nated provi ders CPT
sign code , and , scan their
ned imag intern ship medi cal coding
financing chanofge.servi Henc e, the for that purpose. Stud managed the
arecare
electronic
alsocontr requacts
charg asemas es of papesupe r ine
reco rviso
rds). r or program faculty,
to ents
is a simu ces radio
to provi logist will be ableable ired to a way ter to is upda
comb ted in healt
“real
lated job expe de more afford selec t an tyappro make up any htime”
caretodeliv reflect the
or other new servih ce. Altho ughrienc e, stude nts are tomay bequali care.priate A heal code for the prov next patielost time. Beca use theery intern and
of
healt
the
care pract these
itione r “stat
(e.g.,” nurse meet ings pract
well
apper,groo
itione ar to med
be inconandth shou care
ld dressider profe
nt(Figu
whoreprese
ssion 1-1)nts is aforphys the sameician
ship
organ venie ally
care contract increases
regul charg
tos,emas ter
izatio
comm
n. Ifthe thepract
ittee)
radiologist had selected an
ice’s patient base, the unlist
phys
numb ed CPT
ician’s assistant).
er ofcode
nt,
(inste
they Each
ad of
are nece
the
new ssary provi to the
der-m
(Figu
finan re 1-4).
cial
anaged ity viabil Icons draw attention to critical areas of
ation the time the office , the third-ng party payer claim
would have initially denied s requirements fic speci CPT codeursem addedent
How
records for review. staff must devo and reimb by the
Avo
patie
id
nt 2, te
content or provide experience-based
Res
to fulfilling contract requthe
ubmitti
In Apri
patie ntsl for200 claim nts,pend
the andingthe subm
Cla
spec Ame ireme ission
ims
ialty care. rican Each Assinsur ociaance tion of comp lexity of copie s of ing
of referr
Coaireme
requ lition nts,metand plan Hea has lth its Plan own s (AAHautho P)rizati
withlist hea oflthparticplanipatins and and on the requ Nati iremeona nts,
l Spebilling
grouacts,
contr p, whic there h inclu are ded 10 differreprent esen sets
tativ
g provi
medders
ofesrequ
ical spe or netw cialt yorks. sociIfeties a healt h care
to disc uss proviclaim der s has
sub
cialt ydead
signe
mission con d
Society
10
lines,Insu
partic
claim ranc recommendations. For example, the HIPAA
s e
Enders
(HFM
provi cou
A), hos
from nte
pitawhic r
ls, Fo
hand rm
from iremeheants lth to plan follow
s, the and Hea 10lthcadifferreent pane
cernipatin
s. A gwork
and claims processing;
The encounter form (Figu
referr phys als ician
can be
among other things,
spe made
cialt .
y organizations, was
created to improve adm
Fina ncia lsl ofMan particage ipatin
men g healt
t Associacare h tionALERT! identifies issues related to the
re 4-2) is the finanthe inistrative processes
improve claims sub cialgrou recoprdiden sourtified
other personne miss
assist health planl stoand recoion processes. The resu
rd treat ed diagnoses andlt serv wasices the rend
ce docu
deveered
waymen
lopmto
s that t health
used by plan
heal sthand care prov ider
providers and s cou security of personal health information in the
ld
the physician’s office, itproviders to improve entthe of patie“tools
is also called a supeclaim nt &durin tips” g doc uments
and delayed claim s. rbill; sinproc the hosp essing italeffic
it isienccalleydby decreas
a char geming astedup
the curre
r. licate, ineligible,
that unte
nt enco medical office.
can r. In
The Coding Tip provides

recommendations and hints for selecting
Coding Tip
A short blank line is located
after some of the codes in
the encounter form (Figure
additional character(s) to FIGU REthe
report 1-4spec
Med
ificical
ICD-assis
10-Ctant and inter nship student 4-2) to allow entry of
M diagn
codes and for the correct use of the coding
reject claims with missing, prepare for
invalid, or incom their next osis code
patie nt. . Medicare administrative contractors
plete diagnosis codes. manuals. Other icons include Managed
Care Alert, Hint, Remember!, and
Caution.
xvi
CHAPTER 1: Health Insurance Specialist Career 19
NOTE: g upper case.

-150 0 claims data usin 12-1) and complete
d
to have an excellent understanding about the career path they want to pursue so as to obtain the appropriate entr y, and enter CMS ic case study (Figure
fication of claims data to the John Q. Publ
certification credentials. For example, hospitals may prefer the AHIMA credentials, while physician’s r to Chapter 11 for clari
offices
● Refe Tabl e 12-1, refe r cise 12.1.
CMS -150 0 claim s instructions in st you whe n you begin work on Exer ion.
may prefer the AAPC credentials. ● As you review
the d claim will also assi e, 2020 Edit
ing Health Insuranc
12-2). The complete
CMS-150 0 claim (Figu
re
ns when completing
any claims associate How to Use This Te x t
d with Understand xvii
● Use these instructio
Summary CM S-1500 claims

com pletion inst
ruc tion s for com
mer cial payers
TAB LE 12-1
r an X in the Group
Claims Instructions
A health insurance specialist’s career is challenging and requires professional training to understand claims
Instructions
Block appeal
processing and billing regulations, possess accurate coding skills, and develop the ability to successfully Othe r box if the patient is covered by
an individual or fam
.
ily health plan. Or, ente
Enter an X in the a group health plan
underpaid or denied insurance claims. A health insurance claim is submitted to a third-party payer or1 government patient is covered by patient’s insurance
Claims Instructions simplify the process of completing Health Plan box if the plan if a group num
ber is printed on the workbook, and
k,
program to request reimbursement for health care services provided. Many health insurance plans require prior
The patient is cove red by a group health on case studies located in this textboo
NOTE: ded
the CMS-1500 for various types of payers. These
approval for treatment provided by specialists.
identification card (or
a group number is inclu r hyphens
e). rance card. Do not ente
While the requirements of health insurance specialist programs vary, successful specialists will develop skills SimClaim™ softwar on the patient’s insu
instructions are provided in tables in Chapters 12 to number as it appears
that allow them to work independently and ethically, focus on attention to detail, and think critically. Medical Enter the health insurance identification
, JANE, M).
1a
practices and health care facilities employing health insurance specialists require them to perform various or spaces in the num
ber. by commas) (e.g., DOE
17. Each table consists of step-by-step instructions for dle initial (separated box to indicate the
first name, and mid
functions. Smaller practices and facilities require specialists to process claims for all types of payers, while larger
Ente r the patient’s last name, spac es). Ente r an X in the appropriate
2 Y (with
completing each block of the CMS-1500 for commercial,
practices and facilities expect specialists to process claims for a limited number of payers. date as MM DD YYY k.
3 Enter the patient’s birth ent’s gender is unknown, leave blan ) (e.g., DOE, JANE, M).
Health insurance specialists are guided by a scope of practice, which defines the profession, delineates patient’s gender. If the
pati (separated by commas
e, and middle initial and enter
BlueCross BlueShield, Medicare, Medicaid, TRICARE,
qualifications and responsibilities, and clarifies supervision requirements. Self-employed health insuranceEnter the policyholder’s last name,
4
first nam
et address on line 1, ente r the city and state on line 2,
specialists are independent contractors who should purchase professional liability insurance. Health ent’ s mai ling address. Enter the stre r the telephone number.
and Workers’ Compensation payers.
care providers and facilities typically purchase bonding, liability, property, and workers’ compensation 5 Enter the pati
the five- or nine-dig
it zip code on line 3.
Do not ente
the policyholder. If the
patient is an
ent’s relationship to
box to indicate the pati
insurance to cover their employees. Employees who demonstrate professional behavior are proud of
Ente r an X in the appropriate in the Othe r box. r the policyholder’s
6 partner, enter an X blank. Otherwise, ente the five- or nine-
their work, and they are recognized as having integrity and discipline. They earn the respect of their unmarried domestic der's address, leave r
colleagues, develop a reputation for being loyal and trustworthy, and are considered team players. The s add ress is the same as the policyhol r the city and stat e on line 2, and ente
If the patient' on line 1, ente
7 r the street address
AAMA, AAPC, AHIMA, and AMBA offer exams leading to professional credentials. Becoming credentialed mailing address. Ente not enter the telepho
ne number.
demonstrates competence and knowledge in the field of health insurance processing as well as coding digit zip code on line 3. Do
(continues)
and reimbursement. Leave blan k.
8
Internet Links
Internet Links
Internet Links are provided to encourage you
AAPC: www.aapc.com
American Association of Medical Assistants (AAMA): www.aama-ntl.org to expand your knowledge at various state and
American Health Information Management Association (AHIMA): www.ahima.org federal government agency sites, commercial sites,
American Medical Billing Association (AMBA): www.americanmedicalbillingassociation.com
Centers for Medicare and Medicaid Services (CMS): www.cms.gov and organization sites. Some exercises require you
U.S. Department of Labor, Bureau of Labor Statistics (BLS): www.bls.gov
6: ICD-10-C M Codi ng CHAP TER
177 to obtain information from the Internet to complete
the exercise.
Review al
4.90 (acute gastrointestin
Multiple Choice
dardize the way additiona
l (duodenal ulcer) and ME2
and exte nsio n code XA9780 is added to Reviews and Exercises
Exte nsion codes stan d to a bleeding, NEC ),
The codes
y) is adde
histopathologresponse. the anatomic location.
informati on (e.g.
Select , anat
the mostomy,appropriate
the letter “X,” and can
never be indicate duodenum as
as DA63/ME24.90& XA9780.
The Reviews test student understanding about
stem code, begi n with are repo rted
tongtheis used a(n) also, use additional
1. The document
reported without its stem
. Cluster codi
codesubmitted payer requesting reimbursement
together Coding conventions such
is called
as code chapter content and critical thinking ability.
one code is repo
a. explanation of rted
benefits. ual categories
to indicate that more than des, excludes, NEC, NOS, resid
using either a forward
health
b.slash (/) or insurance nd
an ampersaclaim. (&) to
.
code
(e.g.,
, inclu
certa in, other, unspecified), and/
or, due to, and with Reviews in coding chapters require students
clinic
describe aadvice.
remittance al case mation.
separate multiple code
c.s that to provide additional infor
d. isprior ess of com
approval
the proc form.bining or also appear in ICD-11
2018, to assign correct codes and modifiers using
Postcoordination coding pletely While ICD-11 was read
y for distr ibuti on in
extension) codes to com
linking multiple (stem and
. For example, duodenal
ulcer there is no time line esta
blished for its adoption
by the
coding manuals. Answers are available from your
describe a clinical case code s DA6 3 es.
with acute hemorrhage
is classified as stem United Stat instructor.
Exercises provide practice applying critical
thinking skills. Answers to exercises are available
ICD -10 -PCS
iew of ICD -10 -CM and from your instructor.
Exercise 6.2 – Overv nt.
plete each stateme (ICD-10-CM)
Instructions: Com , Clinical Modification
ases, 10th Revision ounters.
The Inte rnat iona l Classification of Dise data from inpa tient and outpatient enc
1. or morbidity
codes and classifies ision , Pro ced ure Classification System
ases, 10th Rev tient encounters only
.
Classification of Dise data from hospital inpa
2. The International
and classifies tes ICD-10-CM and
ICD-10-
(ICD-10-PCS) codes Services (CM S) abb revia
icare and Medicaid
3. The Centers for Med
. the patient, which
PCS as picture or findings of
-10-CM is to describ
e the istical groupings and
4. The intent of ICD thos e nee ded for ICD-9-CM’s stat
e precise than
means codes are mor have
trend analysis. rely alphanumeric, and
characters, are enti
-10- CM cod es require up to
5. ICD y 19
tions. to verif
unique coding conven te codes for conditio
ns and a ER 1: Health Insuran
CHAPT ce Specia list Career
an index to initially loca
6. ICD-10-CM uses
codes. .
/PCS codes was man
dated by
they want toical pursue so as to of
obtain the appropriate
-10-CM
ICDrstan ding about the careerspath
7. The
to have an excel lent of
reporting unde
mitt ed claim ensures the med credentials, while physician’s offices
AHIM A as “the
es on sub
cod ple, hospitals may prefe r the h is defi ned
g ICD -10-
ntials CM exam
. For encounter, whic
certif8. Repnortin
icatio crede to patients during an ry for the
prefe proc
r edu
the res andcrede
AAPC servicesntials . ided
prov
re rend ered is reas onable and necessa
may service or procedu
determination that a
diagnosis or treatme
nt of an illness or injur
y.”
provider who assesses
and treats Summary
ent and a health care
con tact between a pati
Summary
face -to- face
9. The
the patient’s conditio
n is a(n) .
pe, evidence, and The Summary at the end of each
ical necessity include purpose, sco al training to understand claims
rmine rmed requires profession
crite ria use
10. insurance specialist’s
The d to detecaree is challe nging and
ability to successfully appeal chapter recaps the key points
A health coding skills, and develop the
processing and billing
. regulations, possess accurate or government
is submitted to a third-party payer of the chapter. It also serves as
claims. A health insurance claim insurance plans require prior
underpaid or denied insurance
for health care services provided. Many health
program to reque st reimbursem ent a review aid when preparing for
by specialists.
approval for treatment provided vary, successful specialists will
develop skills
While the requirements of health
insurance specialist programs
and think critically. Medical
tests.
atten tion to detail ,
ntly and ethically, focus on
that allow them to work independe specialists require them to perfo
rm various
es employing health insurance all types of payers, while larger
practices and health care faciliti alists to proce ss claim s for
facilities require speci
functions. Smaller practices and a limited number of payers.
specialists to process claims for
practices and facilities expect ice, which defin es the profe ssion
, deline ates
are guide d by a scop e of pract
Health insurance spec ialists n requi reme nts. Self-e mplo yed health insurance
ities, and clarif ies supe rvisio . Health
qualif icatio ns and respo nsibil profe ssion al liabili ty insurance
actor s who shou ld purch ase
spec ialists are indep ende nt contr bond ing, liabili ty, prope rty, and workers’ comp ensation
ally purch ase xvii
care providers and facilities typic nstrate profe ssion al behavior
are proud of
oyees. Employees who demo
insurance to cover their empl g integ rity and discip line. They earn the respe ct of
their
nized as havin rs. The
their work, and they are recog and trustw orthy , and are cons idere d team playe
for being loyal ming crede ntiale d
colleagues, deve lop a reputation s leadin g to profe ssion al crede ntials. Beco
A offer exam as coding
AAM A, AAPC, AHIM A, and AMB h insurance proce ssing as well
know ledge in the field of healt
demo nstrates comp etenc e and
and reimbursem ent.
HOW TO USE SIMCLAIMTM CMS-1500 SOFTWARE
SimClaimTM software is an online educational tool designed to familiarize you with the basics of the CMS-1500
claims completion. Because in the real-world there are many rules that can vary by payer, facility, and state,
the version of SimClaimTM that accompanies this textbook maps to the specific instructions found in your
Understanding Health Insurance textbook.
How to Access
Student practice software is available through the online MindTap program, accessed at
http://login.cengage.com.
General Instructions and Hints for Completing

CMS-1500 Claims in SimClaimTM
Please read through the following general instructions before beginning work in the SimClaimTM program:
●● Certain abbreviations are allowed in the program—for example, ‘St’ for Street, ‘Dr’ for Drive, ‘Rd’ for
Road, ‘Ct’ for Court. No other abbreviations will be accepted as correct by the program.
●● Only one Diagnosis Pointer in Block 24E per line—though SimClaimTM allows for more than one
Diagnosis Pointer to be entered, only one diagnosis pointer is allowed in Block 24E for each line item as per
textbook instructions.
●● No Amount Paid Indicated—If there is no amount paid indicated on the case study, leave the field blank.
●● Secondary Insurance Claims—If a Case Study indicates that a patient’s Primary Insurance payer has
paid an amount, fill out a second claim for the Secondary Insurance that reflects the amount reimbursed by
primary insurance when indicated.
●● Fill out Block 32 only when the facility is other than the office setting, as indicated on the Case Study.
●● Enter all dates as listed on the Case Study.
●● For additional help using SimClaimTM, refer to the specific payer guidelines found in your textbook.
xviii
CHAPTER
Health Insurance
Specialist Career
1
Chapter Outline
Health Insurance Overview Independent Contractor and Employer Liability
Career Opportunities Professionalism
Education and Training Professional Associations and Credentials
Job Responsibilities
Chapter Objectives
Upon successful completion of this chapter, you should be able to:
1. Define key terms related to the health insurance specialist career.
2. Briefly summarize health insurance claims processing and the parties involved.
3. Identify career opportunities available for health insurance specialists.
4. List the education and training requirements of a health insurance specialist.
5. Describe the job responsibilities of a health insurance specialist.
6. Differentiate among types of insurance purchased by contractors and employers.
7. Explain the role of workplace professionalism for a health insurance specialist.
8. Identify coding and reimbursement professional associations and credentials offered.
Key Terms
AAPC bonding insurance errors and omissions health insurance
American Association business liability insurance specialist
of Medical Assistants insurance ethics Healthcare Common
(AAMA) Centers for Medicare explanation of benefits Procedure Coding
American Health and Medicaid Services (EOB) System (HCPCS)
Information (CMS) hold harmless clause
HCPCS level II codes
Management claims examiner independent contractor
health care provider
Association International Classification
coding health information
(AHIMA) of Diseases,
Current Procedural technician
American Medical 10th Revision,
Terminology (CPT) health insurance claim
Billing Association Clinical Modification
(AMBA) embezzle (ICD-10-CM)
2 CHAPTER 1: Health Insurance Specialist Career
International medical assistant professionalism scope of practice

Classification of medical malpractice property insurance workers’ compensation
Diseases, 10th insurance insurance
reimbursement
Revision, Procedural
medical necessity specialist
Coding System
(ICD-10-PCS) national codes remittance advice (remit)
internship professional liability respondeat superior
insurance
Introduction
The career of a health insurance specialist (or reimbursement specialist) is a challenging one, with opportunities
for professional advancement. Individuals who understand claims processing and billing regulations, possess
accurate coding skills, have the ability to successfully appeal underpaid or denied insurance claims, and
demonstrate workplace professionalism are in demand. A review of medical office personnel help-wanted
advertisements indicates the need for individuals with all of these skills.
Health Insurance Overview

Most health care practices in the United States accept responsibility for filing health insurance claims, and
some third-party payers (e.g., BlueCross BlueShield) and government programs (e.g., Medicare) require
providers to file claims. A health insurance claim is the documentation submitted to a third-party payer
or government program requesting reimbursement for health care services provided. In the past few years,
many practices have increased the number of employees assigned to some aspect of claims processing.
This increase is a result of more patients having some form of health insurance, many of whom require
prior approval for treatment by specialists and documentation of post-treatment reports. If prior approval
requirements are not met, payment of the claim is denied. According to BlueCross BlueShield, if an
insurance plan has a hold harmless clause (patient is not responsible for paying what the insurance plan
denies) in the contract, the health care provider cannot collect the fees from the patient. It is important to
realize that not all insurance policies contain hold harmless clauses. However, many policies contain a no
balance billing clause that protects patients from being billed for amounts not reimbursed by payers (except
for copayments, coinsurance amounts, and deductibles). (Chapter 2 contains more information about
these concepts.) In addition, patients referred to nonparticipating providers (e.g., a physician who does
not participate in a particular health care plan) incur significantly higher out-of-pocket costs than they may
have anticipated. Competitive insurance companies are fine-tuning procedures to reduce administrative
costs and overall expenditures. This cost-reduction campaign forces closer scrutiny of the entire claims
process, which in turn increases the time and effort medical practices must devote to billing and filing claims
according to the insurance policy filing requirements. Poor attention to claims requirements will result in
lower reimbursement rates to the practices and increased expenses.
A number of health care providers sign managed care contracts as a way to combine health care delivery and
financing of services to provide more affordable quality care. A health care provider (Figure 1-1) is a physician
or other health care practitioner (e.g., nurse practitioner, physician’s assistant). Each new provider-managed
care contract increases the practice’s patient base, the number of claims requirements and reimbursement
regulations, the time the office staff must devote to fulfilling contract requirements, and the complexity of referring
patients for specialty care. Each insurance plan has its own authorization requirements, billing deadlines, claims
requirements, and list of participating providers or networks. If a health care provider has signed 10 participating
contracts, there are 10 different sets of requirements to follow and 10 different panels of participating health care
providers from which referrals can be made.
FIGURE 1-1 Health care providers viewing an

electronic image of a patient’s
chest x-ray.
Rules associated with health insurance processing (especially government programs) change frequently;
to remain up-to-date, insurance specialists should be sure they are on mailing lists to receive newsletters
from third-party payers. It is also important to remain current regarding news released from the Centers for
Medicare and Medicaid Services (CMS), which is the administrative agency within the federal Department
of Health and Human Services (DHHS). The Secretary of the DHHS, as often reported on by the news media,
announces the implementation of new regulations about government programs (e.g., Medicare, Medicaid).
The increased hiring of insurance specialists is a direct result of employers’ attempts to reduce the cost of
providing employee health insurance coverage. Employers renegotiate benefits with existing plans or change
third-party payers altogether. The employees often receive retroactive notice of these contract changes; in some
cases, they must then wait several weeks before receiving new health benefit booklets and new insurance
identification cards. These changes in employer-sponsored plans have made it necessary for the health care
provider’s staff to check on patients’ current eligibility and benefit status at each office visit.
Health insurance claims must include accurate codes. Coding is the process of assigning ICD-10-CM,
ICD-10-PCS, CPT, and HCPCS level II codes, which contain alphanumeric and numeric characters (e.g., A01.1,
0DTJ0ZZ, 99201, K0003), to diagnoses, procedures, and services. Diagnoses are documented conditions or
disease process (e.g., hypertension). Procedures are performed for diagnostic (e.g., lab test) and therapeutic (e.g.,
cholecystectomy) purposes, and services are provided to evaluate and manage patient care.
Coding systems include:
●● International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM): coding
system used to report diseases, injuries, and other reasons for inpatient and outpatient encounters, such as
an annual physical examination performed at a physician’s office
●● International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS): coding
system used to report procedures and services on inpatient hospital claims
●● Healthcare Common Procedure Coding System (HCPCS, pronounced “hick picks”), which currently
consists of two levels:
Current Procedural Terminology (CPT): coding system published by the American Medical
Association that is used to report procedures and services performed during outpatient and physician
office encounters, and professional services provided to inpatients
HCPCS level II codes (or national codes): coding system published by CMS that is used to report
procedures, services, and supplies not classified in CPT
4 CHAPTER 1: Health Insurance Specialist Career
(On December 31, 2003, CMS phased out the use of HCPCS level III codes [or local codes]. However, some
third-party payers continue to use the codes.)
In addition to an increase in insurance specialist positions available in health care practices, opportunities are
also increasing in other settings. These opportunities include:
●● Claims benefit advisors in health, malpractice, and liability insurance companies
●● Coding or insurance specialists in state, local, and federal government agencies, legal offices, private
insurance billing offices, and medical societies
●● Medical billing and insurance verification specialists in health care organizations
●● Educators in schools and companies specializing in medical office staff training
●● Writers and editors of health insurance textbooks, newsletters, and other publications
●● Self-employed consultants who provide assistance to medical practices with billing practices and claims
appeal procedures
●● Consumer claims assistance professionals who file claims and appeal low reimbursement for private
individuals. In the latter case, individuals may be dissatisfied with the handling of their claims by the health
care provider’s insurance staff.
●● Practices with poorly trained health insurance staff who are unwilling or unable to file a proper claims
appeal
●● Private billing practices dedicated to claims filing for elderly or disabled patients
Medical necessity involves linking every procedure or service code reported on the claim to a condition code
(e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to perform that procedure
or service (Figure 1-2).
EXAMPLE 1: The provider will not receive reimbursement when a claim is submitted with a CPT code for a right knee
x-ray and an ICD-10-CM code for shoulder pain. For medical necessity purposes, the provider must document a valid
reason for the knee x-ray (e.g., fracture, right patella).
PROCEDURE: Knee x-ray, right
DIAGNOSIS: Shoulder pain
EXAMPLE 2: The provider will receive reimbursement when a claim is submitted with a CPT code for a chest x-ray and
an ICD-10-CM code for severe shortness of breath because medical necessity has been met.
PROCEDURE: Chest x-ray
DIAGNOSIS: Severe shortness of breath
Career Opportunities
According to the Occupational Outlook Handbook published by the U.S. Department of Labor—Bureau of
Labor Statistics, the employment growth of claims adjusters and examiners will result from more claims
being submitted on behalf of a growing elderly population. Rising premiums and attempts by third-party
payers to minimize costs will also result in an increased need for examiners to scrupulously review claims.
Although technology reduces the amount of time it takes an adjuster to process a claim, demand for these
jobs will increase anyway because many tasks cannot be easily automated (e.g., review of patient records to
determine medical necessity of procedures or services rendered).
Health insurance specialists (or reimbursement specialists) review health-related claims to match
medical necessity to procedures or services performed before payment (reimbursement) is made to the
provider. A claims examiner employed by a third-party payer reviews health-related claims to determine
whether the charges are reasonable and for medical necessity. Medical necessity involves linking every
FIGURE 1-2 Health insurance FIGURE 1-3 Medical assistant performing the
specialist locating administrative task of reviewing
code number for a record for documentation
entry in CMS-1500 completeness.
claims software.
procedure or service code reported on the claim to a condition code (e.g., disease, injury, sign, symptom,
other reason for encounter) that justifies the need to perform that procedure or service (Figure 1-2).
The claims review process requires verification of the claim for completeness and accuracy, as well as
comparison with third-party payer guidelines (e.g., expected treatment practices) to (1) authorize appropriate
payment or (2) refer the claim to an investigator for a more thorough review.
A medical assistant (Figure 1-3) is employed by a provider to perform administrative and clinical tasks
that keep the office or clinic running smoothly. Medical assistants who specialize in administrative aspects of
the profession answer telephones, greet patients, update and file patient medical records, complete insurance
claims, process correspondence, schedule appointments, arrange for hospital admission and laboratory
services, and manage billing and bookkeeping.
Health insurance specialists and medical assistants obtain employment in clinics, health care clearinghouses,
health care facility billing departments, insurance companies, and physician offices, as well as with third-party
administrators (TPAs). When employed by clearinghouses, insurance companies, and TPAs, employees often have
the opportunity to work at home, where they process and verify health care claims using an Internet-based application
server provider (ASP). (Information about salaries and job opportunities can be located at the www.bls.gov, www
.aapc.com, and www.ahima.org websites.) Health information technicians also perform insurance specialist functions
by assigning codes to diagnoses and procedures and, when employed in a provider’s office, by processing claims for
reimbursement. (Health information technicians manage patient health information and medical records, administer
computer information systems, and code diagnoses and procedures for health care services provided to patients.)
In addition to an increase in insurance specialist positions available in health care practices, opportunities are
also increasing in other settings. These opportunities include:
●● Claims benefit advisors in health, malpractice, and liability insurance companies
●● Coding or insurance specialists in state, local, and federal government agencies, legal offices, private
insurance billing offices, and medical societies
●● Medical billing and insurance verification specialists in health care organizations
●● Educators in schools and companies specializing in medical office staff training
●● Writers and editors of health insurance textbooks, newsletters, and other publications
●● Self-employed consultants who provide assistance to medical practices with billing practices and claims
appeal procedures
●● Consumer claims assistance professionals who file claims and appeal low reimbursement for private
individuals. In the latter case, individuals may be dissatisfied with the handling of their claims by the health
care provider’s insurance staff.
Another random document with
no related content on Scribd:
The Project Gutenberg eBook of Computers—the
machines we think with
This ebook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it away
or re-use it under the terms of the Project Gutenberg License
included with this ebook or online at www.gutenberg.org. If you
are not located in the United States, you will have to check the
laws of the country where you are located before using this
eBook.
Title: Computers—the machines we think with
Author: D. S. Halacy
Release date: January 1, 2024 [eBook #72572]

Most recently updated: February 3, 2024
Language: English
Original publication: New York: Harper & Row, 1962
Credits: Aaron Adrignola, Tim Lindell, Linda Cantoni and the

Online Distributed Proofreading Team at
https://www.pgdp.net (This book was produced from
images made available by the HathiTrust Digital
Library.)
*** START OF THE PROJECT GUTENBERG EBOOK

COMPUTERS—THE MACHINES WE THINK WITH ***
COMPUTERS—THE MACHINES WE
THINK WITH
Computers—
THE MACHINES WE THINK

WITH
D. S. HALACY, Jr.
HARPER & ROW, PUBLISHERS

NEW YORK, EVANSTON, AND LONDON
COMPUTERS—THE MACHINES WE THINK WITH. Copyright © 1962, by Daniel
S. Halacy, Jr. Printed in the United States of America. All rights in
this book are reserved. No part of the book may be used or
reproduced in any manner whatsoever without written permission
except in the case of brief quotations embodied in critical articles and
reviews. For information address Harper & Row, Publishers,
Incorporated, 49 East 33rd Street, New York 16, N.Y.
Library of Congress catalog card number: 62-14564
F-S
Contents
1. Computers—The Machines We Think 1

With
2. The Computer’s Past 18
3. How Computers Work 48
4. Computer Cousins—Analog and Digital 72
5. The Binary Boolean Bit 96
6. The Electronic Brain 121
7. Uncle Sam’s Computers 147
8. The Computer in Business and Industry 171
9. The Computer and Automation 201
10. The Academic Computer 219
11. The Road Ahead 251

COMPUTERS—THE MACHINES WE
THINK WITH
1: Computers—The Machines
We Think With
While you are reading this sentence, an electronic computer is

performing 3 million mathematical operations! Before you read this
page, another computer could translate it and several others into a
foreign language. Electronic “brains” are taking over chores that
include the calculation of everything from automobile parking fees to
zero hour for space missile launchings.
Despite bitter winter weather, a recent conference on computers
drew some 4,000 delegates to Washington, D.C.; indicating the
importance and scope of the new industry. The 1962 domestic
market for computers and associated equipment is estimated at just
under $3 billion, with more than 150,000 people employed in
manufacture, operation, and maintenance of the machines.
In the short time since the first electronic computer made its
appearance, these thinking machines have made such fantastic
strides in so many different directions that most of us are unaware
how much our lives are already being affected by them. Banking, for
example, employs complex machines that process checks and
handle accounts so much faster than human bookkeepers that they
do more than an hour’s work in less than thirty seconds.
General Electric Co., Computer Dept.
Programmer at console of computer used in electronic processing of bank

checking accounts.
Our government is one of the largest users of computers and

“data-processing machines.” The census depends on such
equipment, and it played a part in the development of early
mechanical types of computers when Hollerith invented a punched-
card system many years ago. In another application, the post office
uses letter readers that scan addresses and sort mail at speeds
faster than the human eye can keep up with. Many magazines have
put these electronic readers to work whizzing through mailing lists.
General Electric Co., Computer Dept.
Numbers across bottom of check are printed in magnetic ink and can be read by
the computer.
In Sweden, writer Astrid Lindgren received additional royalties for

one year of 9,000 kronor because of library loans. Since this was
based on 850,000 total loans of her books from thousands of
schools and libraries, the bookkeeping was possible only with an
electronic computer.
Computers are beginning to take over control of factories, steel
mills, bakeries, chemical plants, and even the manufacture of ice
cream. In scientific research, computers are solving mathematical
and logical problems so complex that they would go forever
unsolved if men had to do the work. One of the largest computing
systems yet designed, incorporating half a million transistors and
millions of other parts, handles ticket reservations for the airlines.
Others do flight planning and air traffic control itself.
Gigantic computerized air defense systems like SAGE and
NORAD help guard us from enemy attack. When John Glenn made
his space flight, giant computers on the ground made the vital
calculations to bring him safely back. Tiny computers in space
vehicles themselves have proved they can survive the shocks of
launching and the environment of space. These airborne computers
make possible the operation of Polaris, Atlas, and Minuteman
missiles. Such applications are indicative of the scope of computer
technology today; the ground-based machines are huge, taking up
rooms and even entire buildings while those tailored for missiles may
fit in the palm of the hand. One current military project is such an
airborne computer, the size of a pack of cigarettes yet able to
perform thousands of mathematical and logical operations a second.
Computers are a vital part of automation, and already they are
running production lines and railroads, making mechanical drawings
and weather predictions, and figuring statistics for insurance
companies as well as odds for gamblers. Electronic machines permit
the blind to read a page of ordinary type, and also control material
patterns in knitting mills. This last use is of particular interest since it
represents almost a full circle in computer science. Oddly, it was the
loom that inspired the first punched cards invented and used to good
advantage by the French designer Jacquard. These homely
forerunners of stored information sparked the science that now
returns to control the mills.
Men very wisely are now letting computers design other
computers, and in one recent project a Bell Laboratories computer
did a job in twenty-five minutes that would have taken a human
designer a month. Even more challenging are the modern-day
“robots” performing precision operations in industrial plants. One
such, called “Unimate,” is simply guided through the mechanical
operations one time, and can then handle the job alone.
“TransfeRobot 200” is already doing assembly-line work in dozens of
plants.
The hope has been expressed that computer extension of our
brainpower by a thousandfold would give our country a lead over
potential enemies. This is a rather vain hope, since the United States
has no corner on the computer market. There is worldwide interest in
computers, and machines are being built in Russia, England,
France, Germany, Switzerland, Holland, Sweden, Africa, Japan, and
other countries. A remarkable computer in Japan recognizes 8,000
colors and analyzes them instantly. Computer translation from one
language to another has been mentioned, and work is even being
done on machines that will permit us to speak English into a phone
in this country and have it come out French, or whatever we will,
overseas! Of course, computers have a terminology all their own too;
words like analog and digital, memory cores, clock rates, and so on.
The broad application of computers has been called the “second
industrial revolution.” What the steam engine did for muscles, the
modern computer is beginning to do for our brains. In their slow
climb from caveman days, humans have encountered ever more
problems; one of the biggest of these problems eventually came to
be merely how to solve all the other problems.
At first man counted on his fingers, and then his toes. As the
problems grew in size, he used pebbles and sticks, and finally
beads. These became the abacus, a clever calculating device still in
constant use in many parts of the world. Only now, with the advent of
low-cost computers, are the Japanese turning from the soroban,
their version of the abacus.
The large-scale computers we are becoming familiar with are not
really as new as they seem. An Englishman named Babbage built
what he called a “difference engine” way back in 1831. This complex
mechanical computer cost a huge sum even by today’s standards,
and although it was never completed to Babbage’s satisfaction, it
was the forerunner and model for the successful large computers
that began to appear a hundred years later. In the meantime, of
course, electronics has come to the aid of the designer. Today,
computer switches operate at billionths-of-a-second speeds and thus
make possible the rapid handling of quantities of work like the 14
billion checks we Americans wrote in 1961.
There are dozens of companies now in the computer
manufacturing field, producing a variety of machines ranging in price
from less than a hundred dollars total price to rental fees of $100,000
a month or more. Even at these higher prices the big problem of
some manufacturers is to keep up with demand. A $1 billion market
in 1960, the computer field is predicted to climb to $5 billion by 1965,
and after that it is anyone’s guess. Thus far all expert predictions
have proved extremely conservative.
The path of computer progress is not always smooth. Recently a
computer which had been installed on a toll road to calculate
charges was so badly treated by motorists it had to be removed.
Another unfortunate occurrence happened on Wall Street. A clever
man juggled the controls of a large computer used in stock-market
work and “made” himself a quarter of a million dollars, though he
ultimately landed in jail for his illegal computer button pushing.
Interestingly, there is one corrective institution which already offers a
course in computer engineering for its inmates.
So great is the impact of computers that lawyers recently met for a
three-day conference on the legal aspects of the new machines.
Points taken up included: Can business records on magnetic tape or
other storage media be used as evidence? Can companies be
charged with mismanagement for not using computers in their
business? How can confidential material be handled satisfactorily on
computers?
Along with computing machines a whole new technology is
growing. Universities and colleges—even high schools—are
teaching courses in computers. And the computer itself is getting into
the teaching business too. The “teaching machine” is one of the
most challenging computer developments to come along so far.
These mechanical professors range from simple “programmed”
notebooks, such as the Book of Knowledge and Encyclopedia
Britannica are experimenting with, to complex computerized systems
such as that developed by U.S. Industries, Inc., for the Air Force and
others.
The computer as a teaching machine immediately raises the
question of intelligence, and whether or not the computer has any.
Debate waxes hot on this subject; but perhaps one authority was
only half joking when he said that the computer designer’s
competition was a unit about the size of a grapefruit, using only a
tenth of a volt of electricity, with a memory 10,000 times as extensive
as any existing electronic computer. This is a brief description of the
human brain, of course.
When the first computers appeared, those like ENIAC and BINAC,
fiction writers and even some science writers had a field day turning
the machines into diabolical “brains.” Whether or not the computer
really thinks remains a controversial question. Some top scientists
claim that the computer will eventually be far smarter than its human
builder; equally reputable authorities are just as sure that no
computer will ever have an original thought in its head. Perhaps a
safe middle road is expressed with the title of this book; namely that
the machine is simply an extension of the human brain. A high-
speed abacus or slide rule, if you will; accurate and foolproof, but a
moron nonetheless.
There are some interesting machine-brain parallels, of course.
Besides its ability to do mathematics, the computer can perform
logical reasoning and even make decisions. It can read and
translate; remembering is a basic part of its function. Scientists are
now even talking of making computers “dream” in an attempt to
come up with new ideas!
More similarities are being discovered or suggested. For instance,
the interconnections in a computer are being compared with, and
even crudely patterned after, the brain’s neurons. A new scientific
discipline, called “bionics,” concerns itself with such studies. Far from
being a one-way street, bionics works both ways so that engineers
and biologists alike benefit. In fact, some new courses being taught
in universities are designed to “bridge the gap between engineering
and biology.”
At one time the only learning a computer had was “soldered in”;
today the machines are being “forced” to learn by the application of
punishment or reward as necessary. “Free” learning in computers of
the Perceptron class is being experimented with. These studies, and
statements like those of renowned scientist Linus Pauling that he
expects a “molecular theory” of learning in human beings to be
developed, are food for thought as we consider the parallels our
electronic machines share with us. Psychologists at the University of
London foresee computers not only training humans, but actually
watching over them and predicting imminent nervous breakdowns in
their charges!
Cornell Aeronautical Laboratory
Bank of “association” units in Mark I Perceptron, a machine that “learns” from

experience.
To demonstrate their skill many computers play games of tick-tack-

toe, checkers, chess, Nim, and the like. A simple electromechanical
computer designed for young people to build can be programmed to
play tick-tack-toe expertly. Checker- and chess-playing computers
are more sophisticated, many of them learning as they play and
capable of an occasional move classed as brilliant by expert human

Full Download pdf of (eBook PDF) Understanding Health Insurance: A Guide to Billing and Reimbursement 15th Edition all chapter

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Full Download pdf of (eBook PDF) Understanding Health Insurance: A Guide to Billing and Reimbursement 15th Edition all chapter

Uploaded by

Copyright:

Available Formats

(eBook PDF) Understanding Health

Insurance: A Guide to Billing and

(eBook PDF) Understanding Health Insurance: A Guide to

Understanding Health Insurance: A Guide to Billing and

(eBook PDF) Health Insurance and Managed Care 5th

(eBook PDF) Understanding Rhetoric: A Graphic Guide to

(eBook PDF) Applied Insurance Analytics: A Framework

(eBook PDF) Understanding Communication Theory: A

(eBook PDF) Understanding Deviance: A Guide to the

(eBook PDF) Understanding Business Valuation: A

Children’s Health Insurance Case Management. . . . . . . . . . . . . 569 Merchant Marine Act

General Equivalence Mappings ICD-10-CM Index and Tabular List

Features of the Text

New to this Edition

Organization of This Textbook

Resources for the Instructor

●● Section IV – Instructor’s Materials

Updates and Resources

Resources for the Student

Student Companion Site

Michelle A. Green, MPS, RHIA, FAHIMA, CPC, has been a

Special thanks are extended to the reviewers, Bridgette Stasher-Booker

Justina Buck Technical Reviewers

The Coding Tip provides

NOTE: g upper case.

Summary CM S-1500 claims

General Instructions and Hints for Completing

International medical assistant professionalism scope of practice

Health Insurance Overview

FIGURE 1-1 Health care providers viewing an

Title: Computers—the machines we think with

Release date: January 1, 2024 [eBook #72572]

Original publication: New York: Harper & Row, 1962

Credits: Aaron Adrignola, Tim Lindell, Linda Cantoni and the

*** START OF THE PROJECT GUTENBERG EBOOK

THE MACHINES WE THINK

HARPER & ROW, PUBLISHERS

Library of Congress catalog card number: 62-14564

1. Computers—The Machines We Think 1

2. The Computer’s Past 18

3. How Computers Work 48

4. Computer Cousins—Analog and Digital 72

5. The Binary Boolean Bit 96

6. The Electronic Brain 121

7. Uncle Sam’s Computers 147

8. The Computer in Business and Industry 171

9. The Computer and Automation 201

10. The Academic Computer 219

11. The Road Ahead 251

While you are reading this sentence, an electronic computer is

Programmer at console of computer used in electronic processing of bank

Our government is one of the largest users of computers and

General Electric Co., Computer Dept.

In Sweden, writer Astrid Lindgren received additional royalties for

Cornell Aeronautical Laboratory

Bank of “association” units in Mark I Perceptron, a machine that “learns” from

To demonstrate their skill many computers play games of tick-tack-

You might also like