CCMA Program Section 5 Pgs 42-51

stress testing

typically completed in hospital environments wehre thorough montioring & emergency equipment is available

-greatest risks associated w this testing is cardiac arrest

-can be conducted in a cardiology specialty setting

-pts are typically attached to heart montioring equipment, & they exercise on a treadmill or stationary bike to see how heart handles the stress

-might receive thallium, which is a dye that provides additional information on blood flow

team based patient care

creates a partnership between providers and patients to ensure patients are educated and actively involved in their care.

-2 common health care delivery models that practice team-based patient care include PCMH & ACO

PCMH

Patient Centered Medical Home

ACO

Accountable Care Organization

Patient-Centered Medical Home (PCMH)

care delivery model whereby patient treatment is most often coordinated thru the PCP to ensure they receive necessary care when & where they need it

-goal of PCMH is to have a centralized setting that facilitates partnerships b/w pt, provider, pt's family

5 core functions & attributes of PCMH

comprehensive care, patient-centered care, coordinated care, accessible services, quality & safety

comprehensive care

an approach that cares for all of the patient's needs -- the whole pt not just medical + physical concerns

-this involves the providers as well as the entire health care team

patient-centered care

positions patients & their families as core members of the team

-the focus is on individual needs & & preferences of the patinet thruout various stages of life

Coordinated Care

means that all specialty care, hospitals, home health care, and community services are overseen by the provider-directed medical practice

-PCMH works at creating & maintaining open communication b/w the pt & other members of the team

-aided by information tech (EMR, EHR)

Accessible Services

include providing tools (open-scheduling, extended hours, communication with providers) through patient information web portals

Quality & Safety

commitments include delivering quality health care. This is met by delivering evidence-based medicine that is assessed by collecting safety data and measuring and responding to patient experiences and satisfaction.

filing systems and processes

conditioning, releasing, indexing & coding, sorting, storing & filing

conditioning

involves grouping related papers tg, removing all paper clips & staples, attaching smlaler papers to reg sheets, fixing damaged records

releasing

marking the form to be filed with a mark of designated preference

- ready to be filed

- provider's initials

- using a stamp

Indexing and coding

Determining where to place the original record in the file and whether it needs to be cross-referenced in another section. A chart number is typically used for this.

sorting

involves ordering papers in a filing structure and placing the documents in specific groups

storing and filing

securing documents permanently in the file to ensure the medical record documents do not become misplaced

copay

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

coinsurance

the sharing of expenses by the policyholder and the insurance company

Deductible

a specified amount of money that the insured must pay OUT OF POCKET before an insurance company will pay a claim

explanation of benefits (EOB)

A statement from an insurance carrier describing what services were paid, denied, or reduced in payment

remittance advice (RA)

an explanation of benefits sent to the provider from the insurance carrier

-similar to the EOB, this ocntains multiple pts & providers

-also included is the electronic fund transfer info or a check for payment

-remittance advice statements are used to post payments to patient accounts

advance beneficiary notice (ABN)

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

ICD-10-CM

International Classification of Diseases, 10th Revision, Clinical Modification

-contains ab 55k more codes than ICD-9-CM & allows more specific reporting of diseases & newly recognized conditions

ICD-10-PS

proxedure coding system is a system comprised of medical classifications for procedural codes typically used within hospitals that record various health treatments & testing

-these codes are a replacement for ICD-9-CM volume 3

CPT codes & modifiers

Current Procedural Terminology (CPT) codes and modifiers are used to document procedures and technical services based on services by providers in outpatient settings.

-all info in the med record must be accurate for correct code to be documented

-using appropriate codes assists in communicating data on procedures & services, correct filing of insurance claims, & provides basic info for statistical analysis of health care services

CMS billing requirements

Information required for completion of the CMS-1500 Form, which includes several fields that must be correctly completed for the claim to be accepted.

-all new pts are asked to fill out a registration form detailing all demographic & insurance info

-then verify insurance info for elegibility & specific requirments

-during this process, determine whether pt requires authorization or referral from insurance carrier

-next review pt med recoreds for accurate documentation of visit

-MA receives encounter form or superbill from provider for the visit to determine the correct or procedural coding & diagnoses are used

-medical documnentation is then reviwed to substantiate the correct charges & confirm accurate diagnoses are used for each procedure

-finally, the claim is sent to the insurance company for reimbursement for services rendered

regular referral

3-10 business days for evaluation/approval

urgent referral

24 hours

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

what to collect when optaining or verifying prior-authorization

authorization code, date the authorization is effective, date the authorization expires, authorized diagnosis & procedural codes, contact info for the specialist office, how many visits are authorized

account balance

the total balance on an account; it can be a debit (negative) or credit (positive)

accounts receivable

amount owed to the provider for services rendered

Accounts Payable

debt incurred but not yet paid; can be for supplies or utilities

debits

represent a record on an account as an addition to expenditure or asset accounts or a subtracted amt amt from income

credits

entry on an acct represented as an addition to profits

assets

property of an individual or org that is subject to payments for debts owed

liabilities

items that are outstanding debts

2 types of billing methods

manual & computerized systems

computerized billing system

Uses software to generate a report for accounts according to the last time a payment was made.

manual billing system

Uses accounting forms, ledgers, or receipts often on a peg board system

-record entries, collections, receivables

to determine if an acct is deliquent

run an aging report

aging report

grouped by day of last payment or by the date of service if no payments have been made

aging reports, collection dues, adjustments, write-offs

depeding on office policies, MA makes reminder call, letters are mailed encouraging pt to make payment or set up payment plan

-if fails, certified letter is mailed requesting payment b4 acct is sent to collections

-when final notice is sent, acct must be sent to collections & all further pt contact regarding the acct must be discontinued

-always treat pt w respect & follow office policies & procedures when making payment arrangements

criminal law

addresses the rules & statutes that define wrongdoings against the community as a whole

crimes can be classified as

misdemeanors or felonies

Misdemeanor

(n.) a crime or offense that is less serious than a felony; any minor misbehavior or misconduct

-carries lesser penalty, usually a fine or imprisonment for less than a year

ex: reckless driving, discharging a firearm in city limits

Felony

a crime, typically one involving violence, regarded as more serious than a misdemeanor, and usually punishable by imprisonment for more than one year or by death.

assault

instance in which someone threatens to cause harm to an individual

battery

intentional touching or the use of force in a harmful manner without the indivudal's consent

plaintiff

individual that files a lawsuit to inititate a legal action

defendant

an individual or group being sued or charged with a crime

subpoena

written order that commands someone to appear in court to give evidence

deposition

formal statement in which the individual who is being deposed promises to tell truth

civil law

applied most often in medical malpractice cases

-governs the private rights of indiciduals, corps, gov bodies & cases involving contracts, family matters, property issues

mutual asset

Agreement to all terms of the contract by all parties to the contract

-must prove there was an offer & acceptance

consideration

a benefit of some type for entering into the contract such as financial reimbursement

capacity

parties must be legally able to contract (legal age, sober)

legality

subject matter must be legal

when a party fails to hold up their part of a contract

they may be sued for breach of contract

in civil law cases

there are usually no fines or imprisonment

plaintiffs may receive

monetary award for injuries sustained as a result of a particuolar incident

In a medical negligence case, the plaintiff may:

receive compensation for medical expenses, lost wages, and for the pain and suffering associated with the negligence

ACA

Affordable Care Act

-reform health care system by providin gmore americans w affordable quality health insurance to curb the growth in health care spending in the US

OSHA

Occupational Safety and Health Administration

-states that employers are accountable for providing a safe & healthful workplace for employees by setting & enforcing standards & by training, outreachm education, assistance

HIPAA

Health Insurance Portability and Accountability Act

-gives pt rights over their health info & sets rules/limits on who can look at & receive pt's priv info

-applies to protected health info whether electronic, written, oral

CSA

controlled substance act

-federal policy that regulates the manufacture & distribution of controlled substances that include narcotics, depressants, stimulants

-classifies med into 5 schedules

Title VII of the Civil Rights Act

Prohibits employment discrimination based on race, color, religion, sex, or national origin.

Equal Pay Act

mandates the same pay for all ppl who do substantially equal work regardless of sex

ADA

Americans with Disabilities Act

—forbids discrimination on the basis of a physical or mental disability if the individual can perform "essential function" of the job.

FMLA

Family and Medical Leave Act

-federal law that requires certain employers to give time off to employees for familial or medical reasons

TJC

The Joint Commission

-helps organizations position for the future of integrated care, strengthen pt safety & quality of care, improve risk management & risk reduction, provide framework for organizational structure & management

HITECH Act

Health Information Technology for Economic and Clinical Health Act

-created to improve health care quality,safety, efficiency for info tech & electronic health records

-provides barriers to info exchange

-act dictates nationwide use of health info tech to encourage an effective marketplace, improved comp,, consumer choice

violation of state med practice acts can result in the provider or health care worker being accused of

malfeasance, misfeasance, negligence, nonfeasance

malfeasance

public misconduct; performing a procedure on wrong pt

misfeasance

The performance of a lawful act in an illegal or improper manner

ex: performing the procedure on correct pt but doing so incorrectly

negligence

failure to do smth that a reasonable person of ordinary prudence would do in certain situations, or the doing of smth that such a persn would not do

Nonfeasance

failure to perform an act that is required by law

ex: waiting to treat a pt until its too late

NHA code of ethics

-use my best efforts for the betterment of society, the profession, and the members of the profession

-uphold the standards of professionalism and be honest in all professional interactions

-continue to learn, apply, and advance scientific and practical knowledge and skills; stay up to date on the latest research and its practical application

-participate in activities contributing to the improvement of personal health, our society and the betterment of the allied health industry

-continuously act in the best interests of the general public

-protect and respect the dignity and privacy all patients

types of medical directives

Living Will

Durable power of attorney for health care

Do-not-resuscitate orders

Organ and tissue donation orders

MOLST

living will

legal document stating what procedures a pt would want, wouldnt want, under what conditions would they want to do organ & tissue donation, dialysis, blood transfusions, DNR

durable power of attorney for health care

document that designates a health care proxy, who is authorized make health care decisions for a client who is unable

Do Not Resuscitate (DNR)

a designation placed on a patient's medical record indicating that in the case of cessation of circulation and breathing, artificial resuscitation (CPR) is not to be done.

organ and tissue donation

orders allow organs or body parts from a healthy person to be transferred to people who need them

MOLST

Medical document that specifies which treatments will be allowed during end of life care. these orders move with the patient if they move facilities, and is bright pink for easy identification