Medical Assistant Skills USA

Auscultation

process of listening for sounds within the body.

Ayer Blade

Wooden or plastic blade used to scrape cells from the cervix of the uterus; used for Pap tests.

Bandage Scissors

Special scissor with a blunt lower end used to remove dressings and bandages.

Dorsal Recumbent

The patient lies on the back with the knees flexed and separated; used for vaginal and pelvic examination.

Electrocardiogram

Graphic tracing of the electrical activity of the heart, ECG or EKG

Fowlers

The patient lies on the back with the head elevated at one of several different angles.

Hemostats

Instrument used to compress(clamp) blood vessels to stop bleeding.

Horizontal Recumbent

(Supine)

Hyperopia

Farsightedness; defect in near vision

jack knife

The patient lies on the abdomen with both the head and legs inclined downward and the rectal area elevated.

Knee-Chest

The patient rests his or her body weight on the knees and chest; used for sigmoidoscopic and rectal exams.

Laryngeal Mirror

Mirror used to examine larynx.

Leads

an angle or view of the heart that is recorded in an electrocardiogram

Left Lateral

(Sims)

Lithotomy

The patient lies on the back with the feet in stirrups and knees flexed and separated.

medication

Drug used to treat a disease or condition.

Myopia

Nearsightedness; defect in distant vision.

Needle Holder

Instrument used to hold or support a needle while sutures (stitches) are being inserted.

Observation

To look at, watch, perceive or notice.

Ophthalmoscope

Instrument used to examine the eye.

Otoscope

Instrument used to examine the ear.

Palpation

The act of using the hands to feel body parts during an examination.

Papanicolaou Test

Also called a pap test; a test to classify abnormal cells obtained from the vagina or cervix.

Percussion

Process of tapping various body parts during an examination.

Percussion Hammer

Instrument used to check reflexes.

Physician's Desk Reference (PDR)

Reference book that contains essential information on medications.

Prone

The patient lies on the abdomen, with the legs together and the face turned to the side.

Retractors

Instrument used to hold or draw back the lips or sides of a wound of incision.

Scapels

Instrument with a knife blade and used to incise skin and tissue.

Sigmoidoscope

Used to examine the sigmoid, or S-Shaped, section of the large intestine.

Sims position

The patient lies on his or her left side with the right leg bent up near the abdomen.

Snellen Chart

Special charts that use letters or symbols in calibrated heights to check for vision defects.

Speculum

Instrument used to dilate, or in large, an opening or passage in the body for examination purposes.

Supine

The patient lies flat on the back, face upward.

Surgical scissors

Special scissors used to cut tissue.

Sutures

Surgical stage used to join the edges of an incision or wound, also, an area where bones join or fuse together.

Suture removal sets

set of instruments, including suture scissors and thumb forceps, used to remove stitches.

Tissue Forceps

An instrument with one or more fine points (tissue) at the tip of blades; are used to grasp tissue.

tonometer

An instrument used to measure intraoccular (within eye) pressure.

Trendelenburg

The patient lies on the back with the head lower than the feet, or with both the head and the feet inclined downward.

tuning fork

An instrument that has two prongs and is used to test hearing acuity.

When taking daily weight notes:

-use the same scale

-make sure the scale is balanced before

-weigh patient at the same time each day

-make sure the patient is wearing same amount of clothes each day

Measurement are recorded on:

National center for health statistics growth graph

Perform general office procedures to standards recognized by American medical association:

Please and receive phone calls

Arrange for a client admission to hospital

Arrange physicians travel accommodations

Schedule client appointments

complete history and assessment for client explained doctors fee and office policies

file letters, diagnostic reports and progress notes and clients records

gather data for necessary reports regarding referrals to other doctors

prepare a medical file for a new client maintain appointment book and reminder system

make referral appointments for client

prepare release form and obtain the necessary signatures

processed mail

prepare medical records for daily appointment schedule

receive clients and visitors

schedule patients for outpatient diagnosis tests

Transcribe letters from Cape recorder or transcriber

prepare statements for mailing

prepare correspondence from rough draft prepare medical records

demonstrate ICD nine CM coding demonstrate CPT coding

apply computer concepts to off his practices plan and organize daily office activities update the outside agency

file of the inventory list of office supplies and equipment

repair purchase requisitions

complete pegboard

operate calculator

Insurance claim

A request sent to an insurance company asking for payment for medical services already provided.

Basic billing process

1. Patient receives care 2. Provider documents visit 3. Codes are assigned (ICD-10 + CPT) 4. Insurance claim form is completed 5. Claim is sent to insurance 6. Insurance processes claim 7. Payment or denial is issued.

CMS-1500

The standard claim form used by healthcare providers to bill private insurance, Medicare Part B, and some Medicaid programs for professional services.

What is CMS-1500 used for?

Doctor visits, office procedures, outpatient services, non-hospital provider billing.

Who fills out the CMS-1500?

Medical assistant or billing staff in the provider's office.

Patient information section

Includes patient name, date of birth, sex, address, and insurance information.

Insured information section

Information about the policyholder (if different from patient).

Diagnosis codes (ICD-10)

Codes that explain why the patient was seen.

Procedure codes (CPT)

Codes that explain what was done during the visit.

Dates of service

When the care was provided.

Provider information

Name, address, and National Provider Identifier (NPI).

Signature on file

Indicates permission to bill insurance.

Medicare

A federal health insurance program primarily for individuals 65 years and older and certain disabled individuals.

Medicare Part A

Covers hospital stays, skilled nursing, hospice, and home health care.

Medicare Part B

Covers doctor visits, outpatient care, preventive services, and medical supplies.

Medicare Part D

Covers prescription drugs.

Medicare claim

Submitted using the CMS-1500 form for Part B services.

Assignment

Agreement by provider to accept Medicare's approved amount as full payment.

Medicaid

A state and federally funded insurance program for low-income individuals and families.

Medicaid claim form

Used to request payment from Medicaid for covered services.

Workers' compensation

Insurance that covers medical care for job-related injuries or illnesses.

First report of injury

Initial documentation of workplace injury.

Workers' compensation claim form

Sent to insurer for payment of medical services.

Third-party payer

An insurance company that pays for healthcare services on behalf of the patient.

Private insurance claim

Submitted to commercial insurance companies using CMS-1500 or electronic claims.

Client reimbursement

When the patient pays out of pocket first and then seeks repayment from insurance.

Reimbursement claim

Form completed by patient or provider to recover payment.

ICD-10 code

Diagnostic code that explains the patient's condition or reason for visit.

CPT code

Procedure code that describes services performed.

Medical necessity

Proof that the service was appropriate and required.

Clean claim

A complete and error-free claim.

Denied claim

Claim not paid due to error or non-coverage.

Rejected claim

Claim not processed due to missing or incorrect information.

Resubmission

Correcting and resending a claim.

Explanation of Benefits (EOB)

A statement from the insurance company explaining what was paid, denied, or applied to the patient's balance.

Release of information (ROI)

Patient permission to share medical information.

Assignment of benefits

Authorization allowing insurance payment to go directly to the provider.

Human structure and function

The study of anatomy (body structures) and physiology (how body parts work together).

Basic human needs

Physical, emotional, social, and safety needs required to maintain health (food, water, shelter, safety, belonging).

Nutrition

The intake and use of nutrients necessary for growth, repair, and maintenance of the body.

Basic mathematical concepts

Addition, subtraction, multiplication, division, fractions, ratios, proportions, and percentages used in healthcare calculations.

Oral communication

Spoken exchange of information with patients, families, and healthcare staff.

Written communication

Documentation and written correspondence that is clear, accurate, and professional.

Telephone communication

Professional handling of calls including identification, message taking, and confidentiality.

Therapeutic communication

Communication that promotes patient comfort, trust, and understanding.

Medical terminology

A standardized language used to describe the human body, conditions, procedures, and treatments.

Documentation

Recording patient data accurately, timely, and legally in medical records.

Interpersonal relationships

Professional interactions that demonstrate respect, empathy, and cooperation.

Cultural competence

Awareness and respect for cultural and language differences in healthcare.

Emotional support

Providing reassurance, empathy, and calm during procedures or treatments.

HIPAA

Health Insurance Portability and Accountability Act; federal law protecting patient health information privacy.

Safety hazards

Conditions that increase risk of injury or illness and must be reported or corrected.

Body mechanics

Proper use of the body to prevent injury during movement or lifting.

Equipment maintenance

Keeping medical equipment clean, functional, and safe for use.

Safe patient environment

An area free from hazards that could cause harm.

Emergency procedures

Planned actions to respond to medical or environmental emergencies.