ccma review

CPT

5-digit codes used for procedures and services

ICD

3–7 digit codes used for medical diagnoses

Superbill/Encounter Form

A document used to record services provided during a visit.

CMS-1500

The standard claim form used for billing; it must include the provider's NPI number.

EOB

sent to the patient - what insurance is covering

Remittance Advice

sent to the provider to explain payments

ABN (Advanced Beneficiary Notice)

A form given to Medicare patients if a service is unlikely to be covered

Medicare

old people

Part A Medicare

Hospital, in patient stuff

Part B Medicare

Medical, outpatient stuff

Part C Medicare

advantage plans (a+b)

Part D

drugs

Medicaid

poor

Order of Draw

Yellow, Light Blue, Red, Marbled Red, Green, Marbeled Green, Lavender/Pink, Gray

Yellow (2)

Cultures/Sterile (SPS)

Light Blue (2)

Coagulation, PT/PTT, (sodium citrate)

Red

Serum test; chemistry studies; blood bank; immunology (no additives)

Green (6)

Chemistry, BMP/CMP, liver, kidneys, hormones, cholestrol (heparin)

Lavender/Pink (5)

Hematology/immunohematology, blood type, A1C, ESR, H/H (EDTA)

Gray

Gluose, EtOH, Lactid Acid (Potassium oxalate and sodium fluoride)

Referrals

The process of sending a patient to a specialist for specific care

Pre-authorization

The requirement to obtain approval from a health insurance provider before a specific procedure or service is performed

Usual and Customary Fees

The standard fees charged by healthcare providers in a specific geographic area for a specific service

Durable Medical Equipment (DME)

Equipment that provides therapeutic benefits to a patient in need because of certain medical conditions and/or illnesses (e.g., wheelchairs, oxygen tanks).

OSHA Form 301

The specific form used for incident reporting of workplace injuries and illnesses

How to Correct Documentation Errors

Errors in a medical record should be corrected by drawing a single line through the error, writing the correction, and initialing/dating the change.

Block Style

A professional format where all lines start at the left margin with no indentations

Simplified Style

A format that typically uses indented paragraphs

Wave Scheduling

Multiple patients are scheduled at the beginning of each hour

Modified Wave Scheduling

Scheduling two or three patients at the top of the hour and another later in the hour

Cluster Scheduling

Booking patients with similar problems or procedures in the same block of time

Double Booking Scheduling

Scheduling two patients to see the provider at the exact same time

Stream/Time Specific Scheduling

Assigning each patient a specific individual time slot

Subjective (SOAP)

Information provided by the patient (e.g., symptoms)

Objective (SOAP)

Measurable data observed by the provider (e.g., vital signs)

Assessment (SOAP)

The provider's diagnosis or medical conclusion

Plan (SOAP)

The treatment steps, medications, or follow-up instructions

Label tubes ______ draw

after

Add ____ to the label

date/time and intials, then place in biohazard bag with lab slip in outside pocket

Check urine temperature within _ minutes. Should be about body temp (90-100)pku

5

pku (newborn screening cards) should be done on the ____. and within ____ hours before the baby leaves the hospital

heel, 24-48

heelsticks are for less than ___ year old. after that, move to finger sticks. use ___ fingers. wipe away first drop of blood

1, middle or ring

tournique stays on for no longer than __ minute to avoid hemoconcentration. hold pressure to avoid hematoma

1

shaking or drawing from small gauge needle causes

hemolysis

if patient is syncope, place them in a

supine position

need verbal or implied consent

never say it wont hurt

Order of hand veins

Median cubital, cephalic, dorsal hand veins, basilic

CLIA waived tests (7)

strep, stool for fecal occult blood test (+ is blue/lavender), Hcg (pregnancy), covid, strep, UA dipstick, glucose

K+ range

3.5-5

Glucose

70-120

Hemoglobin range

Men (13-17) Women (12-15) Average 15

Hematocrit range

Men 41-50, Women 36-46 (avg 45)

Order to DON PPE - put on

bottom to top (gown, mask, goggles, gloves)

Order to DOFF PPE - take off

gloves, goggles, gown, mask

Sterile (removes EVERYTHING)

autoclave needs to get to 250, steam/moist heat, indicator needs to change colors, only sterile for 30 days

Disinfection (kills most pathogens on not real objects)

10:1 bleach/water solution

Sanitation

(60% or higher alcohol for hand sanitizer)

Pediculosis

Lice

Helminths

pinworms

standard precautions apply to

everyone

airborne

chickenpox need N-95

droplet

flu, covid - need surgical mask

contact

MRSA, VRE - need gloves, gown

dispose sharps container when __ full. also never recap dirty needles

3/4

1 kg = __ lb and 37 C = __ F

2.2, 98.6

5 patient rights

dose, drug, time, patient, and route

Subcutaneous Insulin Injection

45 degrees, back of arm, abdomen, inner thigh

Intradermal

15 degrees, forearm, back, allergy testing

Intramuscular

90 degrees, (deltoid, gluteal, vastus lateralis for kids)

Transdermal patch

rotate it, remove old before you place new, fold in ½ to dispose, wear gloves

antitussive

coughing

expectorant

help with thinning and loosening mucus

analgessic

pain

TDAP every __ years

10

Hep B starts in

hospital also series of 3 shots

MMR

6/18 months

Mammogran age

40

Colon cancer screenings

45

bone density

women over 65

pap smear

21

patient centered medical home

a care model focusing on comprehensive, team-based primary care

Snellen/E-chart

Distance vision (Myopia), 1 eye at a time from 20 ft away

Jaeger

Close vision (Hyperopia)

Ishihara

Color blindness

webber tests for equal hearing on both sides

put tuning fork in middle of head

for ear stuff — adult pull: and under 3 pull:

adult = up/back —— child = down/back

Simple Fracture

"closed" fracture; the bone is broken, but the skin remains intact

Compound Fracture

"open" fracture; the broken bone pierces through the skin, creating an external wound

Comminuted Fracture

The bone is splintered, crushed, or broken into multiple small pieces or fragments

when checking bp, pump cuff to

30 mmHg above radial pulse cessation

EKG Paper Speed

Standard speed is 25 mm/sec

Conduction Cycle

SA -> AV -> Bundle of His -> Purkinje fibers

Somatic Tremor

EKG artifact caused by body movement

Wandering Baseline

EKG artifact often caused by poor electrode contact.

AC Interference

electrical interference that appears as small, consistent spikes on the EKG tracing, often caused by nearby electronic devices or power cords.

Interrupted Baseline

break in the EKG tracing where the line disappears or bounces, typically caused by a disconnected lead wire or a broken electrode cable