Preface |
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ix | |
PART 1 THE HEALTH CARE ENVIRONMENT |
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1 | (102) |
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Introduction to Managed Care and Medical Insurance |
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2 | (36) |
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3 | (3) |
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6 | (2) |
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Medical Insurance Reimbursement |
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8 | (2) |
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10 | (8) |
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18 | (2) |
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Regulations and Accreditation in Medical Insurance |
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20 | (2) |
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Employment as a Medical Insurance Specialist |
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22 | (9) |
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31 | (7) |
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Introduction to Claims Processing |
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38 | (41) |
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39 | (9) |
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Overview of the Claim-Processing Sequence |
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48 | (2) |
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Collection of Patient Information |
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50 | (5) |
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55 | (5) |
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Encounter Form Preparation and Coding |
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60 | (3) |
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Linkage and Compliance Review |
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63 | (1) |
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Provider Payment Calculations |
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64 | (1) |
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65 | (2) |
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67 | (1) |
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Third-Party Payer Adjudication |
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67 | (1) |
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Reimbursement Follow-up and Record Retention |
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68 | (3) |
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71 | (8) |
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79 | (24) |
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79 | (2) |
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Safeguarding Confidential Information |
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81 | (9) |
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Insurance Fraud and Abuse |
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90 | (2) |
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Fraud and Abuse Prevention |
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92 | (1) |
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Medical Professional Liability |
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93 | (2) |
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95 | (8) |
PART 2 PHYSICIAN CODING GUIDELINES |
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103 | (112) |
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Diagnostic Coding: Introduction to ICD-9-CM |
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104 | (34) |
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Introduction to Diagnostic Coding |
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104 | (1) |
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105 | (2) |
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Organization of the ICD-9-CM |
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107 | (1) |
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107 | (4) |
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111 | (5) |
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Supplementary Classifications |
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116 | (2) |
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118 | (1) |
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119 | (5) |
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Codes for Circulatory Diseases, Neoplasms, Burns, and Fractures |
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124 | (5) |
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129 | (9) |
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Procedural Coding: Introduction to CPT-4 and HCPCS |
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138 | (47) |
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Introduction to Procedural Coding |
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138 | (1) |
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Current Procedural Terminology, Fourth Edition (CPT-4) |
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139 | (2) |
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141 | (2) |
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143 | (4) |
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147 | (2) |
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149 | (1) |
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150 | (1) |
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Evaluation and Management Codes |
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151 | (9) |
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160 | (2) |
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162 | (4) |
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166 | (2) |
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Pathology and Laboratory Codes |
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168 | (1) |
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169 | (1) |
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170 | (4) |
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174 | (11) |
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Coding Linkage and Compliance |
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185 | (30) |
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185 | (2) |
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187 | (6) |
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Fraudulent Actions and Compliance Errors |
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193 | (3) |
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Strategies for Compliance: The Compliance Plan |
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196 | (5) |
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201 | (6) |
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207 | (8) |
PART 3 CLAIMS PROCESSING |
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215 | (92) |
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Provider Charges and Payment Methods |
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216 | (30) |
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216 | (1) |
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217 | (6) |
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223 | (5) |
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Calculations of Patient Charges |
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228 | (8) |
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236 | (10) |
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The Universal Health Insurance Claim Form: HCFA-1500 |
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246 | (31) |
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246 | (1) |
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247 | (11) |
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258 | (6) |
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Electronic Claims and Administrative Simplification |
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264 | (4) |
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268 | (9) |
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Claim Adjudication, Reimbursement Follow-up, and Record Retention |
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277 | (30) |
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277 | (1) |
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278 | (4) |
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Claim Monitoring and Follow-up |
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282 | (3) |
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Electronic Remittance Advice (ERA) Processing |
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285 | (5) |
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Appeals, Postpayment Audits, and Refunds |
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290 | (1) |
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Patient Billing and Collections |
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291 | (6) |
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297 | (2) |
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299 | (8) |
PART 4 HEALTH CARE PAYERS |
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307 | (216) |
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Managed Care Contracts and Private Payers |
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308 | (35) |
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308 | (4) |
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312 | (10) |
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Fee-for-Service Claim Management |
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322 | (4) |
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326 | (1) |
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Private Payer Claim Completion |
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327 | (5) |
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332 | (11) |
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343 | (56) |
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343 | (1) |
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344 | (4) |
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348 | (1) |
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Nonparticipating Providers |
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349 | (3) |
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352 | (4) |
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Medigap and Supplemental Insurance |
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356 | (4) |
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Medicare as the Secondary Payer |
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360 | (2) |
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362 | (1) |
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Preparing Medicare Claims |
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363 | (14) |
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377 | (1) |
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377 | (5) |
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382 | (17) |
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399 | (23) |
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399 | (1) |
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400 | (3) |
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403 | (2) |
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Medicaid Enrollment Verification |
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405 | (1) |
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Covered and Excluded Services |
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405 | (4) |
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409 | (1) |
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410 | (1) |
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411 | (1) |
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412 | (1) |
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Medicaid Claim Completion |
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413 | (2) |
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415 | (7) |
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422 | (27) |
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422 | (1) |
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423 | (1) |
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Provider Participation and Nonparticipation |
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424 | (1) |
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425 | (3) |
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428 | (1) |
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428 | (1) |
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Tricare and Other Insurance Plans |
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429 | (1) |
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429 | (8) |
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437 | (1) |
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437 | (4) |
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441 | (8) |
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Blue Cross and Blue Shield |
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449 | (24) |
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449 | (1) |
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450 | (1) |
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Blue Cross and Blue Shield Member Plans |
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450 | (4) |
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454 | (1) |
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454 | (1) |
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Federal Employee Health Benefits Plan |
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455 | (1) |
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Provider Participation and Nonparticipation |
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455 | (3) |
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458 | (1) |
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458 | (7) |
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465 | (8) |
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Workers' Compensation and Disability |
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473 | (24) |
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473 | (1) |
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Occupational Health and Safety Administration |
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474 | (1) |
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Federal Workers' Compensation Plans |
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474 | (1) |
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State Workers' Compensation Plans |
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474 | (3) |
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Classification of Injuries |
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477 | (1) |
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Workers' Compensation Terminology |
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478 | (1) |
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479 | (4) |
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483 | (1) |
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Disability Compensation Programs |
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484 | (1) |
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484 | (2) |
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Preparing Disability Reports |
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486 | (1) |
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487 | (10) |
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Hospital Billing: The UB-92 Claim Form |
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497 | (26) |
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497 | (1) |
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Health Care Facilities: Inpatient versus Outpatient |
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498 | (2) |
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Hospital Claims Processing |
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500 | (6) |
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Inpatient (Hospital) Coding |
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506 | (2) |
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Payers and Payment Methods |
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508 | (3) |
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511 | (7) |
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518 | (5) |
Appendix: Guide to MediSoft |
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523 | (16) |
References |
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539 | (2) |
Abbreviations |
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541 | (1) |
Glossary |
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542 | (9) |
Index |
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551 | |