NHA CCMA Study Guide - Medical Assisting and Insurance Fundamentals

Comprehensive practice flashcards covering insurance terminology, patient positioning, medication schedules, anatomy, clinical procedures, EKG, and medical law from the NHA CCMA study guide.

Advance beneficiary notice (ABN)

A form provided to the patient when the provider believes Medicare will probably not pay for services received.

Allowed amount

The maximum amount a third-party payer will pay for a particular procedure or service.

Copayment

An amount of money that is paid at the time of medical service.

Coinsurance

A policy provision whereby the policyholder and the insurance company share the cost of covered losses in a specified ratio, such as 80:20.

Deductible

A specific amount of money a patient must pay out of pocket before the insurance carrier begins paying.

Explanation of benefits (EOB)

A statement from the insurance carrier detailing what was paid, denied, or reduced in payment, including amounts applied to the deductible and coinsurance.

Participating provider (PAR)

Providers who agree to write off the difference between the amount charged by the provider and the approved fee established by the insurer.

Medicare Part A

Federal government plan that generally covers hospitalization for patients age 65 and older.

Medicare Part B

Federal government plan that generally covers routine medical office visits for patients age 65 and older.

Tricare

A plan that authorizes dependents of military personnel to receive treatment from civilian providers at the expense of the federal government.

CHAMPVA

Covers surviving spouses and dependent children of veterans who died as a result of service-related disabilities.

Medicaid

Provides health insurance to the medically indigent population through a cost-sharing program between federal and state governments.

Managed care

An umbrella term for plans providing health care for preset scheduled payments and coordinated care through a defined network.

Workers' compensation

Protects wage earners against loss of wages and medical costs resulting from occupational accidents or disease, provided the employee is not negligent.

CMS-1500 Form section 1

The Carrier Block, containing the address of the insurance carrier at the top of the form.

CMS-1500 Form section 2

Patient/Insured Section; includes boxes 1 through 13 containing information about the patient or insured.

CMS-1500 Form section 3

Physician/Supplier Section; includes boxes 14 to 33 containing information about the physician or supplier.

Schedule I Controlled Substances

Substances with high potential for abuse and no approved medical use in the U.S., such as heroin, LSD, and cannabis.

Schedule II Controlled Substances

Dangerous substances with high abuse potential leading to psychological and physical dependence; examples include morphine, fentanyl, and methamphetamine.

Schedule II Prescription Rules

Providers must give patients a handwritten prescription with no refills, and staff must store them in a secure, locked cabinet separate from other medications.

Schedule III Controlled Substances

Substances with moderate to low potential for dependence, such as ketamine and anabolic steroids; refills allowed five times in 6 months.

Schedule IV Controlled Substances

Substances with low potential for abuse and dependence, such as diazepam and alprazolam; staff may authorize refills over the phone.

Schedule V Controlled Substances

Substances containing limited quantities of narcotics for antidiarrheal, antitussive, and analgesic purposes, such as pregabalin.

Household to Metric: 1 teaspoon (tsp)

$$5\,mL$$

Household to Metric: 1 tablespoon (tbsp)

$$15\,mL$$

Weight Conversion

$$1\,kilogram\,(kg) = 2.2\,pounds\,(lb)$$

Intramuscular (IM) Administration

Injected into the deltoid, vastus lateralis, or ventrogluteal muscles; CCMA is permitted to administer.

Subcutaneous (SC) Administration

Injected under the skin of the abdomen, anterior thighs, or outer arm; includes implantable devices like insulin pumps.

Fat-soluble vitamins

Vitamins A, D, E, and K.

Water-soluble vitamins

Vitamins B1, B2, B3, B6, folate, B12, pantothenic acid, biotin, and C.

Apathy

Defense mechanism involving indifference or a lack of interest, feeling, concern, or emotion.

Conversion

Defense mechanism involving the transformation of anxiety into a physical symptom that has no cause.

Regression

Defense mechanism involving the reversion to an earlier, more childlike, developmental behavior.

Sublimation

Defense mechanism involving rechanneling unacceptable urges or drives into something constructive or acceptable.

Superior (cranial)

Anatomical direction meaning above or closer to the head.

Inferior (caudal)

Anatomical direction meaning below or closer to the feet.

Anterior (ventral)

Anatomical direction meaning toward the front of the body.

Posterior (dorsal)

Anatomical direction meaning toward the back of the body.

Proximal

Closer to the trunk of the body.

Distal

Farther away from the trunk of the body.

Sagittal plane

A vertical plane that divides the body into right and left portions.

Transverse plane

A horizontal plane that divides the body into upper and lower portions.

Sinoatrial (SA) node

The pacemaker of the heart where the electrical impulse is generated.

Atrioventricular (AV) node

Also called the gatekeeper of the heart's electrical conduction system.

Chain of infection

Links including infectious agent, reservoir host, portal of exit, mode of transmission, portal of entry, and susceptible host.

Normal Adult Heart Rate

$60$ to $100/min$

Pulse Oximetry

A noninvasive tool to ascertain the percentage of oxygen saturation in the blood; a reading of $95\%$ or higher is normal.

Systolic pressure

The pressure recorded when the first sharp tapping sound is heard during blood pressure measurement (Phase I Korotkoff sound).

Diastolic pressure

The pressure noted when the last sound disappears completely and blood flows freely (Phase V Korotkoff sound).

Hypertension threshold

Blood pressure reading of $140/90\,mm\,Hg$ or higher.

Normal Adult Respiratory Rate

$12$ to $20/min$

Radial pulse location

The thumb side of the wrist; most common site for taking an adult pulse.

Fowler's position

Sitting position with the back of the exam table raised to a $90^{\circ}$ angle; used for eye, ear, nose, throat, or chest exams.

Sims' (lateral) position

Lying on the left side with the left leg slightly flexed and the right leg flexed at a $90^{\circ}$ angle; used for rectal exams and enemas.

Lithotomy position

Lying flat on the back with buttocks at the end of the table and feet in stirrups; used for female pelvic exams.

Trendelenburg position

Legs elevated above the head to force circulation to vital organs; used for patients in shock.

Intradermal (ID) needle specifications

$27$ to $28$ gauge needle, $3/8\,inch$ length, injected at a $10^{\circ}$ to $15^{\circ}$ angle.

Intramuscular (IM) needle specifications

$20$ to $23$ gauge needle, $1$ to $3\,inches$ length, injected at a $90^{\circ}$ angle.

Vastus lateralis muscle

Injection site routinely used for vaccines and medications in infants and children younger than 3 years old.

Buccal route

Medication placed between the cheek and gums for rapid absorption bypassing the digestive system.

Sublingual route

Medication placed under the tongue, such as nitroglycerin tablets.

Sanitization

The first step in cleaning medical equipment, reducing the number of microbes to a lower level often via friction or ultrasonic sound waves.

Disinfection

The process of destroying pathogens on a surface; common solutions include glutaraldehyde or a 1:10 bleach solution.

Sterilization

The removal of all micro-organisms using dry heat, gas, chemicals, UV radiation, ionizing radiation, or steam under pressure (autoclave).

Expected Hemoglobin (Hgb) range

Males: $13$ to $18\,g/dL$; Females: $12$ to $16\,g/dL$.

Fasting blood glucose (FBS) reference range

$60$ to $110\,mg/dL$

Ishihara book

A screening tool for color blindness; identifies red-green deficiencies using 11 plates.

Order of draw: Light Blue

Contains Sodium citrate (anticoagulant); used for coagulation studies.

Order of draw: Lavender

Contains EDTA (anticoagulant); used for whole blood hematology determinations.

EKG Paper vertical axis

Represents gain or amplitude; each small square is $0.1\,millivolts\,(mv)$, and normal amplitude is $10\,mm$ ($1\,mv$).

EKG Paper horizontal axis

Displays time; each small horizontal square is $0.04\,seconds$, and normal speed is $25\,mm/second$.

P wave

Represents atrial depolarization or contraction.

QRS wave

Represents ventricular depolarization or contraction.

T wave

Represents ventricular repolarization or relaxation.

Wandering baseline

EKG artifact resulting from poor electrode connection, often associated with lotions, oils, or powders on the skin.

Holter monitoring

Ambulatory monitoring where patients keep a diary of activities and avoid showers and metal detectors while wearing trunk electrodes.

Patient-centered medical home (PCMH)

A delivery model where care is coordinated through a primary care provider to ensure comprehensive, patient-centered, and accessible service.

Remittance advice (RA)

An explanation of benefits sent from the insurance carrier to the provider containing payment posting information.

ICD-10-CM format

Three to seven characters; first is alphabetical, second/third are numeric, and 4th-7th are alphabetic or numeric.

Upcoding

Coding for more than what was performed to receive higher reimbursement; considered fraud.

Stat referral

A referral for an emergent situation that can be approved immediately via telephone after being faxed to utilization review.

Accounts receivable

The amount owed to the provider for services rendered.

Malfeasance

Performance of an unlawful, wrongful act, such as performing a procedure on the wrong patient.

Misfeasance

Performance of a lawful action in an illegal or improper manner.

MOLST

A bright pink medical document specifying treatments allowed during end-of-life care that moves with the patient between facilities.