Comprehensive Study Guide for CCMA Module 11: Administrative Assisting in Healthcare Settings

Practice Management Systems

Systems used for patient records, scheduling, registration, and billing in healthcare facilities. (administrative side of the EHR)

Electronic Medical Record (EMR)

Digital version of a patient's medical and health care information within a specific health care organization.

Electronic Health Record (EHR)

• a record of patient medical and health care information accessible to providers and other staff members with log-in credentials regardless of location.

• This contributes to more efficient patient workflow.

• Results in more accuracy and efficiency and a greater continuity of care for the patient.

• Lab and diagnostic orders can be entered and viewed by the patient and their providers in real time

Administrative Side of EHR

Scheduling appointments, tracking patient demographics, billing procedures, insurance claims, and processing payments.

Paper-based Filing Systems

• Traditional method for medical records (Charts)

• Disadvantages: cumbersome, allows access of one user at a time, and lacks real-time interoperability among providers. looking for charts can be time consuming

Filing paper charts

most common is alphabetic filing by patient's last name

Inside paper chart

Records are are assembles in reverse chronological order. Most recent medical services on top

real time adjudication (RTA)

A tool that allows for a submission of the coded visit to the insurance company by participating providers for reimbursement decisions by third-party payers while the patient is present.

Electronic records

Most organizations and medical providers have made the shift for reasons including:

• more accurate

• efficient

• incentives from health and human services (HHS) and CMS

Centers for Medicare and Medicaid Services (CMS)

A federal agency that oversees the Medicare program and assists states with Medicaid programs.

Cloud Storage for EHR

Typical storage method for electronic health records, with real-time backup and offsite accessibility.

Archived Medical Records

Stored at offsite locations for retrieval as necessary, especially for medical history, patient care, or legal matters.

Medical Record Retention

Varies by state, but must be stored appropriately and in accordance with state regulations, maintaining privacy and confidentiality.

Federal and State Privacy Regulations

Regulations that must be maintained for effective health care delivery, regardless of the method of storage (electronic or paper).

Patient Portal

Personal account for instant access to health records and test results

Schedule Matrix

the designed timeframe for appointments based on the method of appointment durations

Specific Time (scheduling method)

A specific time gives each patient an individual time for their appointment

Wave scheduling

Scheduling 2 to 3 patients during a designated hourly time period. Patients are seen in the order they arrive. This gives more flexibility within each hour

Double-booking

This system books 2 patients at the same time for their appointment and then provides medical services concurrently. Beneficial if one has labs or test that need to be done and the provider can alternate between their care

Clustering

Patients are scheduled in groups with common medical needs (schedule all new patients on tuesdays or all wellness exams on fridays)

New patient

Has not received services from the provider or same group within 3 years - includes known complaint/condition

Established patient (could include follow-up, sick, or consultation)

Received services from the same provider or group within 3 years- includes known complaint/condition

Comprehensive

New or established pt. for a specified complaint at highest coding level, multiple complaints, injuries, or worsening chronic condition

Preventive care (complete physical exam, annual wellness exam, chronic care management)

Thorough review of body systems including preventive care and screenings

Urgent

Medically necessary within 24 hours

Other entities

non-patient related (depositions, sales, representatives, staff meetings, training)

MA's should ask the following questions to determine what type of appointment is needed

1. Consider the medical resources needed to conduct the appointment

2. Ask the reason for the visit (time needed)

3. Ask the patient for their preference of time and day (give them a few options)

4. Ask if they prefer a telehealth or in-person visit

Screening to identify type of appt. needed

1. ask questions to determine patient's s/s and history of current condition

2. Patients name and contact info

3. reason for the visit

4. Determine if there is a need to route the call (clinical staff, billing)

5. Policies should clearly define what are considered urgent matters and how calls are handled (decision tree)

When should patients come in to allow for time to fill out or update required paperwork

at least 15 mins before the appointment

Duration of appointments

• New patient: 60 min

• Established patient: 15 min

• Comprehensive: 45-60 min

• Preventive care (wellness exam): 45-60 min

• Urgent: 20 min

• Other entities: 30 min

MA's asking questions to determine the appt. priority

• if emergency or life-threatening should be referred to ER

• MA's can not diagnose or offer treatments for medical conditions.

• General guidance on recommendations for nonprescription treatments can be offered as patient education under the direction and policy of the organization

Patient check-in

1.Patient check-in starts when the patient arrives for their appt.

2.MA's should be cordial and professional

3.MA will verify the pt's identity, eligibility, and insurance info

4.Ask to see photo id (valid DL) to verify the name and DOB match the info on the insurance card and patient medical record

5.MA will ask pt. to verify pt. demographics and update as needed

6. Pt registration forms will be checked to confirm they have been uploaded to pt. account

7. Insurance card and valid state photo id will be scanned into the system (pt's can decline having picture or id scanned)

Verifying patient insurance eligibility

MA will also determine any copayments or patient financial responsibilities to be collected before medical services are rendered. Inform pt. of amounts due at time of service when the appt. is made

Patient check-out process

• Occurs after the medical encounter has been completed.

• Review the after-visit summary and ask if the patient has any questions or concerns

• Any f/u should be noted and highlighted for the patient

• In the event of additional patient financial responsibility such as deductible or coinsurance owed, it would be collected at check out

after-visit summary (AVS)

Information that includes follow-up appointments, provider orders, instructions, educational resources, and financial account information.

Deductible

Amount you must pay before you begin receiving any benefits from your insurance company

Coinsurance

The percentage of the allowed amount the patient will pay once the deductible is met.

Required documentation for patient review and signature

1. Patient demographics

2. Medical history

3. Notice of privacy practices (NPP)

4. Patients bill of rights

5. Assignment of benefits

6. Any medical records release forms

These forms inform the pt. of expectations and office policies and collect pt info for the medical record and billing purposes

Notice of Privacy Practices (NPP)

Document that identifies how the provider will distribute and disclose a patient's protected health information.

Administrative section of the medical record

1. patient's demographics

2. Notice of Privacy Practices (NPP)

3. Advance Directives

4. Consent forms

5. Medical release forms

6. Correspondence and messages

7. Appointment and billing info

Clinical section of the Medical record

1. Health history

2. Physical exam

3. Allergies

4. Medication record

5. Problem list

6. Progress notes

7. Lab data

8. Diagnostic procedures

9. Continuity of care ( consultation reports, home health reports, hospital documents)

Medical Record

• Is a legal document

• Corrections to paper document- adding or correcting entry by drawing a line through the data and adding new data- never permanently delete. Include the date and your name.

• Keep all info in the medical record confidential and private. Compliance must always be maintained

Encounter form/ Superbill

• Records the diagnosis and procedures covered during the current visit.

• List of diagnosis and procedure codes most commonly used by the practice

Chart review

performed to make sure the encounter, prescriptions, follow-up, and communications are all completely and accurately documented

The diagnosis code (ICD-10-CM)

are the reason for the visit, such as tonsillitis or an annual exam.

Procedure codes (CPT)

Include medical services provided such as an exam or laboratory work

Utilization review

• a process used by payers to inform providers about policy payments, benefits, and authorizations.

• Elective and costly procedures, therapies, diagnostic imaging, prescriptions, and lab test can require utilization review before they are scheduled or provided

Precertification

A request to determine if a service is covered by the patient's policy and what the reimbursement would be.

preauthorization

• Approval of insurance coverage and necessity of services prior to the patient receiving them.

• These requests are usually submitted electronically and include the following:

• Providers info, patient's demoographic and insurance info, description of the service requested, the pt's diagnosis, ICD-10-CM code and CPT codes, along with any info to justify the need for service and proposed time the service will be performed

Referral

A patient can request their PCP to refer them to a specialty care provider to receive medical services.

1. Can be done over the phone, via EHR, or visiting the payer website or provider portal

2. Many 3rd party payers require the patient to schedule an appointment with their PCP to discuss the need of the referral

3. MA's will assist with making the appt for the pt.

4. Referrals are considered part of HIPPA exclusions for treatment, Payments, and operations so a separate signed release of medical information form is not needed unless required by organization

Verifying patient eligibility

• Must be verified when appt is scheduled and on date of service.

• It ensures the pt's policy is in effect and the third pary payer covers the medical services

What to do when a pt. receives services or calls to schedule an appt.

1. verify demographics and update as needed

2. Verify a government issued ID card and scan a copy of the insurance card into the system

3. Patient eligibility can be verified by calling the the insurance or using the eligibility application in the EHR or payer's web-based service

Explanation of Benefits (EOB)

a detailed account of each claim processed by an insurance plan, which is sent to the patient as notification of claim payment or denial

Collecting patient financial responsibility amounts

• Be sensitive and considerate, some patients might not realize they will have to pay.

• Be sure to communicate effectively the payment options which can include: cash, credit, or payment plans

Diagnosis codes (ICD-10-CM)

1. assigned according to the reason for the visit

2. They are assigned for billing purposes with third-party payer and are part of the medical record

3. They are 3-7 alphanumeric characters long and begin with a letter.

4. They describe the condition, cause, manifestation, location, severity, and type of injury or disease

ICD-10-PCS codes

Only for hospital/inpatient

Procedural codes (CPT and HCPCS)

• Assigned according to what medical services were provided relating to the diagnosis code

• Include medical procedures and services provided

• 5 digits and can have a 2 digit modifier to provide additional info

CMS Billing and Documentation Requirements

• CMS publishes documentation guidelines to ensure timely, accurate, and efficient documentation occurs.

• The lack of proper documentation can have a detrimental effect on pt. care and can result in denied or inaccurate reimbursements from third party payers

Advanced Beneficiary Notice (ABN)

• is a form used for fee-for-service Medicare beneficiaries when the service may not be covered. The patient must be informed the service may or may not be covered and has the option to agree to be financially responsible for the payment. The ABN form is presented and signed before the services are provided.

• *if an ABN is not signed prior to service and Medicare denies the claim the pt. is not responsible for the amount and the provider will not be paid

Charge reconciliation

• The process of ensuring that the accounts are all balanced and accurate.

• The MA can manually post charges, payments, and adjustments.

• Patients receive statements indicating charges and amounts paid and their final financial obligation that is due.

Revenue Cycle

• The cycle for healthcare organization includes all finance-related aspects. The MA is involved in each step of the cycle, from verifying pt. eligibility to ensuring that the appropriate reimbursement has been received.

• The patient's records, documentation, coding and billing, claim submission, payment posting, and f/u are parts of an effective revenue cycle

Incentive models

• part of transition from FFS (fees for service) to value-based programs.

• Incentives/disincentives based on provider performance of achieving certain quality and clinical measures and providing patient satisfaction

• Examples of incentive models: Pay for performance (P4P), Accountable Care Act (ACO), Patient -Centered Medical Home (PCMH)

Accounts Receivables (A/R)

Includes anticipated payments for medical services billed, followed up by the MA to ensure due money is collected.

aging report

A report that lists outstanding balances that have not been paid by either the patient or the insurance payer.

Health record auditing

done to ensure that documentation is complete, correct, and signed by the provider and that the details support the codes (e.g., CPT, HCPCS, and ICD-10-CM) reported for reimbursement and quality purposes.

Billing patients, insurers, and third-party payers for medical services

• Utilizing EHR and practice management software makes the process more efficient.

• Allows for generating patient statements for their financial responsibility of the overall costs by generating to the patient portal or paper for mailing.

• Health care organization can determine timing- monthly billing or cycle billing

Cycle billing

producing monthly statements for subsets of customers at different times (ex. a-f billed 1st week of the month)

Collecting patient financial responsibility

• Copayments and predetermined patient financial responsibilities should be collected at the time of service, and patients should be notified prior to arriving to the appt.

• Patients methods of payments: cash, credit card, check, payment plans

Clearinghouse

An organization that accepts the claims data from a health care provider, performs edits comparable to payer edits, and submits clean claims to the third-party payer.

Denied Claims

claim returned to the provider by payers due to coding errors, missing information, and patient coverage issues

Follow up calls

• Patients can access results on patient portals

• If abnormal results, policy may state contact patients by phone.

• Only leave the name of the practice if it does not reveal the purpose of the call

No-show

When a patient misses a scheduled appointment without notice

Appointment Reminders

• Methods to inform patients of scheduled appointments, reducing no-show rates

• Ex. Automated calls, patient portals messages, appt. cards, email or text

Documented Communication

Recording all patient interactions and follow-ups in the patient record

Tips when placing outgoing calls to patients

1. open pt's medical record

2. have all needed info available prior to the call

3. Allow enough time and double check phone number

4. MA should identify themselves and confirm if this call time is convenient

5. Only give info to pt. or authorized individuals (on pt. signed privacy agreement)

6. Voicemail: MA should state only the name of the individual the message is intended for, date, and time, their name and practice name and phone number and hours to return call

Template

Sample form for creating written correspondence, such as appeal letters or memos. Must be HIPAA compliant, free from spelling errors and grammatically correct.

Charge Directory

List of billable items and corresponding codes and amounts

Data Analysis Applications

Software for compiling and retrieving health care data for reports

Drop-down Menus

Selection lists to input information, reducing typographical errors

Supply chain

consists of a relationship between a company and its suppliers to produce and distribute a specific product to buyers checking delivered supplies

Supply Error Notification

Reporting any discrepancies in delivered supplies to the practice manager or supplier

Inventory supply log

Form tracking the office's inventory and predicting needed amounts

Checking delivered supplies

• MA will check to make sure the supplies sent match what was ordered and the correct amount

• If any errors contact the office manafer or the supplier directly

• Check supplies ASAP may need to be refrigerated (vaccines)

• Log and document items received

Shipping box storage

Supplies should be removed from shipping boxes to prevent contamination

Threshold (par level)

Minimum inventory amount before placing a new order

Activate patient portal

• Allows patients access to their records, labs, radiology reports, progress notes, immunizations, pt. financial responsibility, medications, messaging the organization, schedule appts. "digital front door"

• Pt's will receive a username and access code

Telehealth/virtual encounters

Remote medical services using secure phone or visual platform

Safety plan

Preventive measures to minimize risks and ensure a safe environment

OSHA

Federal agency responsible for inspecting and ensuring workplace safety

Equipment inspection logs

Records of routine checks and maintenance for clinical and administrative equipment

Insurance Plan Tiers

Levels of coverage by the plan, affecting patient out-of-pocket expenses.

Interoperability

Supports sharing patient information using common standards, reducing unnecessary services and ensuring timely and appropriate care

MACRA

Medicare Access and CHIP Reauthorization Act of 2015, implementing changes in reimbursement methods for Part B providers

Quality metrics

Used to report care details and screenings, influencing reimbursement and focusing on quality over quantity of services

CMS (Centers for Medicare and Medicaid Services)

overseeing Medicare and Medicaid programs, providing documentation guidelines and specific publications

ABN (Advance Beneficiary Notice of Noncoverage)

form for informing Medicare beneficiaries about services that may not be covered

Patient account reconciliation

Responsibility to ensure balanced and accurate accounts, including posting payments and adjustments

Revenue cycle

Encompasses all finance-related aspects impacting potential revenue earned and collected by a healthcare organization

Aging Reports

Lists outstanding balances not paid by patients or insurance payers, used to address older debts and identify potential collections.

Accounts Receivables (A/R)

Includes anticipated payments for medical services billed, followed up by the MA to ensure due money is collected.