NHA CCMA ADMINISTRATIVE ASSISTING

Wave scheduling

3 patients scheduled at the same time, see in the order that they arrive (so one pt arriving late does not disrupt schedule)

Modified wave scheduling

Allocates 2 pts to arrive at a specified time and the 3rd to arrive approximately 30 min later, or pts are seen in intervals during 1st half of the hour with no pts seen during 2nd half of the hour; timely sequence continuous throughout the day

Wave scheduling

3 patients scheduled at the same time, see in the order that they arrive (so one pt arriving late does not disrupt schedule)

Modified wave scheduling

Allocates 2 pts to arrive at a specified time and the 3rd to arrive approximately 30 min later, or pts are seen in intervals during 1st half of the hour with no pts seen during 2nd half of the hour; timely sequence continuous throughout the day

Double-booking

2 pts are scheduled at the same time to see the same provider; used to work in a pt with an acute illness when no other time is available; creates delays

can also be used to schedule 2 pts for the same time slot in an office with multiple providers for short visits

Cluster scheduling

grouping pts who have similar conditions into specific time slots or days

Open hours scheduling

pts arrive at their convenience and are seen on first-come, first-served basis

Scheduling an internal appointment with a patient

Name, DOB, reason for visit

Determine amount of time, day and time the pt prefers, and consider availability/provider preferences/pt habits

Scheduling an external appointment (new pt)

Name, DOB, address, contact, insurance, SSN, emergency contact

Give registration packet with medical history form and notice of privacy practices

How much time for a new patient appointment?

30 minutes minimum

What should you tell a patient if there is a delay?

They have the option to wait or reschedule

Notice of Privacy Practices

A notification by providers required by the HIPAA Privacy Rule that provides an understandable explanation of patients' rights with respect to their personal health information and the privacy practices of their providers

How long should a patient wait in the waiting room?

No more than 15 minutes

Steps for filing medical records

1. Conditioning (group related papers together, rmv clips/staples, attaching smaller papers to larger sheets, fixing damaged records)

2. Releasing (marking form to be filed)

3. Indexing and coding (determining where to place the original record in the file and whether it needs to be cross-referenced in another section)

4. Sorting (ordering papers in filing structure)

5. Storing and filing (securing documents permanently to ensure they don't become misplaced)

Alphabetic filing

Last name, first name, middle initial

Traditional system most widely used

Numeric filing

Arranging files by a numbered order

Combined with color coding and used for larger health centers/hospitals

Saves time, additional confidentiality, unlimited expansion

Subject filing

Either an alphabetic or alphanumeric code is assigned to general correspondence

Shingling filing

New report laid on top of older report

How long to keep a Medicare or Medicaid patient record

10 years

Source-oriented medical record (SOMR)

Patient file organized according to the source of information/who supplied the data

Lab, radiology

SOAP

subjective, objective, assessment, plan

CHEDDAR

chief complaint, history, examination, details, drugs/dosages, assessment, return visit information or referral

Computerized physician order entry (CPOE)

Electronic medical record system function that allows providers to digitally order lab and radiology testing, treatments, referrals, Rx

Increased use due to HITECH act

Primary forms of identification

Photo ID (driver's license) and insurance cards

Collected at beginning of the visit

Information needed to verify insurance

Name, DOB, policy number, SSN

Copay

A specified sum of money based on the patient's insurance policy benefits due at the time of service

Coinsurance

The amount a policyholder is financially responsible for according to insurance policies provisions (i.e. 80:20)

Deductibles

Specific amounts of money a patient must pay out of pocket before the insurance carrier begins paying, usually on a calendar year accrual basis

Explanation of Benefits (EOB)

Provided to pt by the insurance company as a statement detailing what services were paid, denied, or reduced in payment; also includes info pertaining to amounts applied to deductible, coinsurance, or allowed amounts

Remittance advice (RA)

Explanation of benefits sent to the provider from the insurance carrier; similar to EOB, contains multiple pts and providers and includes electronic fund transfer information or check for payment; used to post payment to pt accounts

Advance beneficiary notice (ABN)

Form a Medicare pt will sign when provider thinks Medicare might not pay for specific service/item; pt has option to choose to have Medicare billed, so official payment decision is made and Medicare Summary Notice sent to pt with explanation for noncoverage, or to not have charges submitted to Medicare, and receive services from the provider with the understanding that the pt is responsible for payment at the time of service w/o ability of appealing to Medicare or deciding not to receive services

Needs to be signed by pt before services are provided with a copy to be kept on file and a copy to be given to the pt

ICD-10-CM contain how many characters?

3-7 characters

Alphanumeric

1st is alphabetical

2nd and 3rd are numeric

4th-7th either alphabetic or numeric

ICD-10-PCS codes contain how many characters?

7

Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes have how many characters?

5

HCPCS codes

Medicare

Downcoding

Unlawful act of 3rd party payer paying for services at a lower rate than contract agreement

Upcoding

Billing for a service at a higher level than was actually provided to receive larger reimbursement from 3rd party payer

"Over-coding"

"Code creep"

"Over-billing"

You should always code to the

highest level of specificity

can help avoid denial of reimbursement

Direct billing

the process by which an insurance carrier allows a provider to submit insurance claims directly to the carrier electronically

Clearinghouse submission

Allows a provider to submit multiple insurance claims electronically in batches for a small fee; uses software to audit and sort claims for various insurance carriers

Universal claim form

The form used to submit all government-sponsored claims; also known as the CMS-1500 form

Chart reviews

Review of medical records to ensure payment is made only for services that meet plan coverage and medical necessity requirements

Goal is to reduce payment errors by identifying and addressing documentation issues or billing errors concerning coverage and diagnosis coding inaccuracies

What 3 factors determine level of service with E/M coding?

History

Examination

Medical decision-making

Steps to processing referrals

1. Complete referral form

2. Obtain prior authorization

3. Give pt a copy of authorization code

4. Document date of referral approval

Regular referrals

3-10 business days for evaluation/approval

Urgent referrals

24 hours for authorization

Stat referral

Emergency situation, approved via telephone immediately once faxed to insurance companies' utilization review department; may need to be justified via peer-to-peer review

Preauthorization

A process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services or refers a patient to a specialist

Contains a range of dates for evaluation and treatment

What can happen if the range of dates for evaluation on a preauthorization expire?

Denial of payment by insurance

Precertification

A process required by some insurance carriers in which the provider must prove medical necessity before performing a procedure

Participating provider

Provider bills the pt only for the deductible, copay, coinsurance, or amounts due based on allowed fees set forth in the contract btwn provider and insurance company and in return, the insurance company agrees to pay the provider's office directly for covered services rendered to the insured

CMS-1500 form

Billing form that contains procedural coding related to patient care

Does not need information like medical record number

Diagnosis code

indicates medical necessity for procedure or treatment to receive reimbursement

CMS-1500 Charges

amount of reimbursement requested

Account balance

Total balance on an account; can be debit (negative, amount owed, subtracted amount from income) or credit (positive, monetary balance in an individual's favor, addition to profits)

Accounts receivable

Amount owed to the provider for the services rendered

Accounts payable

Debt incurred but not yet paid (can be for supplies/utilities)

Assets

Property of an individual or organization that is subject to payments for debts owed

Liabilities (what is still owed) + capital (what has been paid)

Liabilities

Items that are outstanding (debts)

What to do if a check returns for non sufficient funds?

Add amount back to pt's account balance

What to do for duplicate payment?

Credit the balance

What to do for overpayment from insurance?

Reimburse insurance and balance pt's account

When to make adjustments

Insurance disallowances

Professional discounts, account write-offs, payments sent to practice after account placed in collection status

Provider's usual charge is more than established allowed amount. Cannot bill the pt for the difference, so write off the difference

Steps to appeal claim denial

Ask why it was denied

Obtain and complete appeal document

Letter from provider to provide support for medical necessity, progress notes, relevant results

Phone etiquette

Hold headset or mouthpiece 1 inch away from lips and directly in front of mouth for clarity

Never use speaker!

Network

a group of two or more computer systems linked together

Database

A collection of data organized in a manner that allows access, retrieval, and use of that data

Cookies

Track browsing history and personalize online experience

Cache

Tracks website that users visit to increase browser speed

Queries

Process information that a database documents, tracks, stores

Data field

Location where data is stored within a computer program

Data entry

Act of typing informant into the data field

Electronic medical record (EMR)

Digital charts to be used within a facility; electronic record of health-related info about an individual that can be created, managed, and accessed by authorized individuals within a single healthcare organization

Electronic health record (EHR)

Include EMR and other information to be used btwn facilities; conforms to nationally recognized interoperability standards and can be created, managed, and accessed by authorized individuals from multiple healthcare organizations

Consumable items

Supply that can be used up (gauze, bandages, alcohol pads)

Expendable items

Important or commonly used (pens, pencils, paper)

Intangible items

No physical presence (positive attitude, enthusiasm, initiative)

Durable item

Equipment used repeatedly (crutches, wheelchairs, walkers)

What should you tell a patient if insurance does not cover their medical bill?

Patient must contact insurer to discuss disputes

What to add to an appointment calendar

Name

Phone number

Reason for visit

A medical assistant is determining the amount a patient will be required to pay for a scheduled procedure that has an allowable amount of $200. The patient has a 90/10 coinsurance and has met his deductible. What is the total amount the patient will pay the provider for the service?

$20

Problem-focused examination

single body area or system mentioned in CC

Expanded problem-focused examination

body area or system in CC as well as related body areas or systems

Detailed examination

include CC, related body areas or systems as well as present and past medical history, family history, social history

Comprehensive examination

complete examination of multiple body systems related and unrelated to the CC, family history, social history, and detailed medical history

What to do if a patient contacts you saying they got a bill for services they did not receive?

Must review the encounter form to see if this patient was seen and what services they received

Encounter form = accounts for changes, payments, balances for each patient

Are not required to pay until services are confirmed, but must confirm if charge was accurate before writing them off

Does not matter if there are other charges

Birthday rule

primary insurance policy is determined by which parent has the earliest birthday month

Medicare claim denial

Fee schedule must follow usual, customary, reasonable requirements for repayment

If charges exceed usual, customary, and reasonable fees? Revisit the charges in question and adjust pt's account to reflect no unpaid charges and write off the balance

Scheduling an outpatient appointment

MUST always begin with obtaining oral or written order from provider before getting authorization, calling outpatient facility, contacting patient for availability

Usual fee

fee most commonly charged by provider for given service

Reasonable fee

fee for services or procedures that requires extra time and effort for the provider due to level of complexity

Customary fee

range of fees charged by providers who have similar training and experience and practice in same geographical area

Capitation

fixed amt money paid to provider by third party payer per individual enrollee for established period

Encounter form (superbill)

contains info about any and all services provided by clinical staff, additional actions (referrals/follow-up appts)

Can you disclose estimated costs of a procedure to a patient?

Yes

What notes can a patient request?

List of medications with diagnoses

Summary of psychotherapy notes

Copies of medical records or images (i.e. of x-rays)

NEVER information for legal proceedings

Against Medical Advice (AMA)

when a noncompliant patient leaves a hospital without physician's permission against advice from the physician

What piece of information is required for referrals?

Diagnosis

Phantom providers

file false claims from offices that don't actually exist. It's all an elaborate fraud scheme designed to get insurance companies to pay out on these false claims.

Phantom billing is a form of

Fraud

Problem-oriented medical record (POMR)

Documentation system organized according to the person's specific health problems

Problem list = social, demographic, medical, surgical concerns

Database = medical history, diagnostic and lab results, ROS, CC, present illness

Progress notes = for every problem; enter chronologically, include CC/treatment/response to treatment

Diagnostic and treatment plan = for each condition and lab/diagnostic test prescriptions

Category I code

special circumstances → use modifier in conjunction to provide further clarification