CCMA Study Guide

Insurance Terminology

  • Advance Beneficiary Notice (ABN): Form for patients when provider believes Medicare may not cover services.

  • Allowed Amount: Maximum amount a third-party payer will pay for services.

  • Coinsurance: Policy provision where the policyholder shares the cost of covered losses with the insurance company in a specific ratio.

  • Explanation of Benefits (EOB): Details from insurance explaining payments made, denials, or reductions.

  • Participating Provider (PAR): Providers who agree to write off differences between billed amounts and allowed amounts.

Types of Insurance Plans

  • Medicare: For individuals 65 and older, includes Part A (hospitalization) and Part B (routine care).

  • Tricare: For military personnel and dependents.

  • CHAMPVA: For surviving spouses or veterans’ dependents.

  • Medicaid: For medically indigent individuals.

  • Managed Care: Plans providing care in exchange for preset payments.

Healthcare Coding and Claims

  • CMS-1500 Form: Claims submitted by providers for reimbursement, including patient and insurance information in boxes 1-33. Elements in the form include demographic info, diagnostic tests, treatment procedures, and billing info.

Positions for Exams

Common patient positions include:

  • Supine: Patient lies flat on their back; often used for abdominal exams and assessments requiring the physician to observe the front of the patient.

  • Sims: Patient is positioned on their side with one leg straight and the other leg bent at the knee; commonly used for rectal exams and certain procedures.

  • Trendelenburg: Patient lies on their back with the pelvis higher than the head; used in emergency situations to increase blood flow to vital organs or during certain surgical procedures.

  • Knee-Elbow Position: Patient is on their knees with the chest down; typically used for specific rectal exams or procedures to provide optimal access.

  • Prone: Patient lies on their stomach; useful for certain examinations of the back or lower extremities.

  • Sitting: Patient is seated upright; often used for cardiovascular or respiratory assessments and certain inpatient or outpatient procedures.

  • Lithotomy: Patient lies on their back with legs elevated and bent at the knees, used for gynecological exams and procedures.

Medication Schedules

  • Controlled Substances Act (CSA): Categorizes drugs by potential for abuse:

    • Schedule I: High potential for abuse (heroin, LSD).

    • Schedule II: High potential but has medical use (oxycodone).

    • Schedule III to V: Lower potential for dependency, varying rules for prescriptions.

  • Common household measurements: teaspoons, tablespoons, fluid ounces, cups, pints, quarts, gallons.

Infection Control

  • Chain of Infection: Steps include infectious organism, reservoir, mode of exit, transmission, entry, and susceptible host.

  • Vital Signs: Normal ranges for heart rate, blood pressure, temperature.

  • Infection prevention via standard precautions and proper hand hygiene.

Patient Education and Procedures

  • Electrosurgery & Cryosurgery: Techniques to minimize bleeding and destroy abnormal tissue.

  • Suture & Staple Removal: Inspect wounds, and methods for removal.

Medical Documentation and Billing

  • Prescription Components: Patient information, medication prescribed, dosage, instructions, and provider signature.

  • Medical Necessity: Guidelines for insurance coverage.

  • Aging Reports: Monitoring accounts receivable and collections.

Legal and Ethical Considerations

  • Criminal vs Civil Law: Understanding legal rights and responsibilities in healthcare.

  • HIPAA: Patient rights regarding health information privacy.

  • Types of Medical Directives: Living wills, DNRs, durable power of attorney.

Conclusion

This summary consolidates critical terms and processes in healthcare related to insurance, patient care, medication administration, infection control, and legal aspects affecting medical practice.