NHA Module 15

no show

a person who fails to keep an appointment without giving advance notice.

Electronic Medical Record

Systematic collection of a patient's health care and treatment in a digital format in the physician's office or medical facility

scheduling matrix

identifies a pattern of working and nonworking hours for the medical office.

wave schedule

allows three pts to be scheduled at the same time, to be seen in the order in which they arrive.-One pt arriving late does not disrupt the provider's schedule..

Modified wave scheduling

a scheduling system similar to the wave system, allocates two patients arriving at planned intervals during the hour, and the third to arrive approximately 30 minutes later, allowing time to catch up before the next hour begins

Double booking scheduling

Two patients are given the same appointment time to see the same provider. This is often used to work when a pt that has an acute illness will be seen when no other time is available. This schedule creates delays in the providers schedule that continues throughout the day.

Internal appointments/established pt

To schedule an established pt you will need pt's name and date of birth and reason for appt, and available time pt can come in.

External appointments /new pt's

need Demographic info such as Full name, address, date of birth, contact phone numbers, insurance info for billing purposes. Social Security number and Emergency contact number. (New pt's should fill out new pt packet prior to coming in.)

New Pt. Packet

Includes: New Pt. Forms for documenting, demographics info, Notice of Privacy Practices. Patient medical history forms, which includes current medication.

duration of the appointment

the most important characteristics of an appointment book, Consider the providers preferences, pt's needs, if pt is new or room availability. Effective scheduling the pt should not wait longer than 15 minutes.

Urgency of Appointments

All calls that come into office should be evaluated and prioritized based on screening process. List of questions should be asked to decide if call is routine, urgent or life-threatening. If consider critical you should remain on the phone until EMS arrives.

Handling cancellations and No-Shows

Cancellations and No-shows should be documented in the Medical Record to protect the provider from legal action.

Recalls (electronic or manual)

Automated call routing system offers pts the options of cancelling. confirming, or rescheduling an appointment. You should contact pts that have cancelled to rescheduled.

Managing electronic records (conditioning)

grouping related papers together, removing all paper clips and staples, attaching smaller papers to regular sheets, and faxing damaged records

releasing

The marking of a document to indicate that the record is ready for filing

Indexing and Coding Files

-Deciding where document is to be filed

-Weather it needs to be cross-referenced in another section

-a chart number is typically used for this.

Sorting

Arranging data in a specified order.

storing and filing

Placing items permanently in the proper location in the filing system so they are not displaced

Three basic filing systems

Alphabetic, Numeric & Subject filing

alphabetic filing system (most popular)

A system of health record identification and storage that uses the patient's last name as the first component of identification and his or her first name and middle name or initial for further definition

numerical filing system

a method of organizing health records according to a unique patient identification number

Subject filing

Either an alphabetic or alphanumeric code is assigned to general correspondence.

Medicare records must be kept a minimum of __ years.

10

Prescription pads

should be locked in a tamper-proof safe at closing

Pt charts

must never leave the office and those that have not yet been filed are to be locked away at closing

HIPAA (Health Insurance Portability and Accountability Act) requires

does not require specific methods for disposal of medical records but facilities should keep detailed record of when, how, and by whom the medical records were destroyed.

chronological order

(Time Order) Events are arranged in the order in which they happened

reverse chronological order

Arranging documents with the most recent document on top or in the front, which means that the oldest document is on the bottom or at the back of a section or file.

SOAP notes

subjective- Impressions, objective-findings or clinical indications, assessment- or medical diagnosis, plan- for treatment

CHEDDAR note stands for:

Chief complaint-History-Examination-Details-Drugs and dosages-Assessments-Return visit information

CPOE (Computerized Physician Order Entry)

Application used by physicians and other health care providers to enter patient care information. Also provides support tools that result in improved care and patient outcomes. includes (Lab & Radiology orders)

Encryption

a process of encoding messages to keep them secret, so only "authorized" parties can read it and a password is required to unlock code.

Firewall

a part of a computer system or network that is designed to block unauthorized access while permitting outward communication.

Medical Records

Files that contain the documentation of patients' medical history, record of care, progress notes, correspondence, and related billing/financial information. Is federally mandated and remains a legal document also used by researchers to gather statistical information.

HITECH Act of 2009

made into a law to promote the adoption and meaningful use of health information technology

meaningful Use

the utilization of certified EHR technology to improve quality, efficiency, and patient safety in the healthcare system

Sending medical records

All requests for medical records need to be provided in writing and the release filed into the pt. chart. Pt's attorney, mediator must obtain approval from pt. to access pt's med. records but attorney may present durable power of attorney document that authorizes them to view the med records on pt behalf

Notice of Privacy Practices (NPP)

a written statement that details the provider's privacy practices should be available to pt's at all times for their review

demographic information

Personal information about the patient; the name, address, and telephone number of the guarantor's employer; the names, addresses, and policy numbers of all health insurance plans covering the patient; the name of the referring physician; and information about any dependents.

two primary forms of ID pt needs to present at check-in

drivers license or state-issued ID and Insurance cards

Consent form

Pt. needs to sign a consent to treat form before the provider sees them, unless its an emergency situation. This is necessary for any treatment or procedures, including exams.

informed consent

A written informed consent must be signed in advance showing in-depth understanding of a treatment

Implied consent

is given when the pt has a minimally invasive procedure such as a venipuncture or an electrocardiogram

Handling visitors in the Dr. office

visitors must have an appt and the provider must be willing to spend the time with them including pharmaceutical representatives vendors, etc. They must have a visitors badge and show ID

Co-payment

a specific amount of money a patient pays for a particular service due at the time of service.

Coinsurance

a provision under which both the insured and the insurer share the covered losses usually the Insurer pays 80% and policyholder pays 20%

Deductible

this is the amount the patient is expected to pay before the insurance plan will begin paying. Deductibles are usually on a calendar year accrual basis

explanation of benefits form (EOB)

A summary prepared by an insurance company, and sent to a policyholder, that documents how the insurance policy covered the charges associated with a particular claim, denied the claim or reduced payment. EOB includes amounts applied to deductible, coinsurance, or allowed amounts.

remittance advice (RA)

An explanation of payments (for example, claim denials) made by third-party payers. used to post payments to patient accounts. The RA contains multiple pt's and provider information.

Advanced Beneficiary Notice (ABN)

An agreement a patient must sign if denial of payment for treatment for Medicare is possible. must be signed before date of service and filed in pt chart

TRICARE

A government health program that serves dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members; formerly called CHAMPUS.

Medicare

A federal program of health insurance for persons 65 years of age and older or who need coverage due to specific medical issues

Workers Compensation

A form of insurance paid by the employer providing cash benefits to workers injured or disabled in the course of employment.

Verifying Insurance Coverage

following information is needed - Pt's full name, Date of birth- Policy number- Social

security number - CCMA should ask the address of where claims should be sent and who they spoke with to obtain information-copays or coinsurance

Federal Truth in Lending Act

arranges for payments that extend longer than 4 months and is used by the Physician to guarantee payment by a pt who is not covered by insurance or medicare/medicaid

ICD-10-CM

International Classification of Diseases, Tenth Revision, Clinical Modification-used for Diagnosis codes 3-7 characters starting with the 1st character being alphabetical and second and third numeric- fourth, fifth, sixth. and seventh can be either alpha-or numeric.

ICD-10-PCS codes

Systems comprised of medical classification for procedural codes typically used within hospitals for billing, such as for supplies used during surgery, is done using ICD-10 PCS codes.

CPT Codes (current procedural terminology)

five digit numeric codes for procedures & services performed by providers

Modifiers (CPT)

a two-digit character that is appended to a CPT code to report special circumstances involved with a procedure or service

HCPCS codes

descriptive terms with letters or numbers or both used to report medical services and procedures for reimbursement. Provides a uniform language to describe medical, surgical, and diagnostic services. HCPCS codes are used to report procedures and services to government and private health insurance programs, and reimbursement is based on the codes reported

CMS-1500 form

Standard insurance form used by all government and most commercial insurance payers.

Explanation of Benefits (EOB)

insurance report that is sent with claim payments explaining the reimbursement of the insurance carrier

Chart Review

consists of collection and clinical reviews of medical records to ensure that payment is made only for services that meet all plan coverage and medical necessity requirements.

problem focused history

chief complaint; brief history of present illness or problem

comprehensive history

Chief complaint, extended history of present illness, review of systems directly related to the problem(s) identified in the history of the present illness in addition to a review of all additional body systems, complete past/family/social history.

encounter form/superbill

Medical document that contains information regarding a patient visit for health care services, can serve as a billing or coding document

auditing methods,-processes-and sign-offs

used to examine records or claims for accuracy and completeness can be performed manually or electronically. Provider signs off on progress notes after they are dictated.

REFERRALS & CONSULTATIONS

is a document or form required by insurance companies that is used when a provider wants to send a pt to a specialist. Can be sent electronically or manually.

Referrals

should only be submitted after the approval of the provider and authorization from the insurance co. has been obtained. Referrals can take 3 to 10 business days for evaluation and approval

Preauthorization/Precertification

The process of obtaining and documenting advanced approval from the health plan by the provider before delivering the medical services needed. This is required when services are of a non emergent nature

HMO (Health Maintenance Organization)

A managed care organization that provides comprehensive medical services for a predetermined annual fee per enrollee. Most HMO's require preauthorizations prior to pts receiving any procedures or tx. outside of primary care

precertifications

most insurances require precertification within 24 hours of the admission dates . Providers must prove medical necessity before performing a procedure

Participating providers

are not allowed to to bill Medicaid patients for their cost of treatment over what is reimbursed for cover services. the Providers must accept the contracted amount agreed upon by the insurance company and pt can only be billed for deductible, copay,or coinsurance

Liabilities are

the debts one owes

Assets

money and other valuables belonging to an individual or business

Accounts Receivable

The total amount of money owed to a provider.

Accounts Payable

is a debt incurred but not yet paid

debit (negative)

an amount recorded on the left side of a T account. recorded as a addition to expenditure or asset accounts

credits, debits

Credit-money paid by one party to the other

Debit-money that is owed by one person to the other

assets and liabilities

Assets: Anything of value owned by a company.

Liabilities: Obligations to be paid to creditors.

manual and computerized billing systems

two types of billing methods. Computerized billing system uses software to generate a report for accounts according to the last time a payment was made. can determine which accounts are 30,60,or 90 days old. Manual can give the same record entries, collections, and receivables, however its more time consuming and requires more time to process than computerized billing system.

NSF check

a check that is not paid by a bank because of insufficient funds in a bank account. Pt can be charged for a returned check

Bankruptcy

A condition under which a person or corporation is declared unable to pay debts. Debts have to be adjusted off the account.

Charge reconciliation

an accounting process providing consistent and accurate figures in offices financial accounts

EFT

Electronic Funds Transfer; exchange of money by sending bank records via a computer network

audit

to check the accuracy of financial accounts and records

delinquent account

One that has not been paid within a certain time frame (20-30-days, 30-60-days- 60-90-90-120 days).

Appeal for denial from an insurer

1st step is determine why the claim was denied. Obtain and complete the insurance company's appeal document

PHI

Protected Health Information

EMR/EHR

Electronic Medical Record/Electronic Health record. Are digital charts to be used within a facility. EHR include the EMR and other info to be used between facilities.

Social Media

Electronic media that allows people with similar interests to participate in a social network Adhere to HIPPA when using social media (never share pictures of pts and never share information on pts.

Administrative supplies

Pens, Pencils, Reams of Paper, Toner cartridges, paper clips, registration forms, Pt.information sheets, clipboards

Inventory

supplies should be ordered, checked against the shipping or packing list when they arrive.

CLIA-waived tests

tests that provide simple, unvarying results and require a minimum amount of judgment and interpretation(CLIA requires controls and settings be performed on all equipment. ensuring pt testing is accurate and test results are reliable

OSHA (Occupational Safety and Health Administration)

division of the federal gov. overseen by the Dept of Labor agency, responsible for reducing workplace injuries, illnesses, and fatalities.

OSHA

requires facilities with more than 10 employees have a written er plan of action, with evacuation plan of action, exit routes, protocols for employees who operate equipment and a list of PPE to be used to prevent exposure to bloodborne pathogens.

Exposure Control Plan (ECP)

Must be given to employees upon request within 15 working days and the plan must be available at all times in the workplace.

SDS(Safety Data Sheet)

details vital information about any product or chemical used in the medical facility. The SDS clarifies the correct use of the product and the proper action if a spill occurs

Mail Merge

is a feature that allows a user to create mass mailings of letters, mailing labels, and other documents and personalize the information in each

SOAP

subjective, objective, assessment, plan