CCMA OVERVIEW

Procedural Coding

  • Importance of Medical Necessity

    • Every procedure performed must have a corresponding procedural code.

    • A procedure can only be billed if there is medical necessity.

    • Example: An ICD code for migraine headaches cannot justify billing for bypass surgery.

    • Claims will be denied if the provided ICD codes do not support the procedure.

Upcoding

  • Definition of Upcoding

    • Referring to charging for a more severe diagnosis to receive higher reimbursements from insurance.

    • Example: A patient has chest pain; instead of just coding for chest pain, upcoding to coronary artery disease allows billing for additional diagnostic tests like an angiogram or EKG.

    • Caution: Medical necessity must still be proven; otherwise, insurance may deny claims.

Durable Medical Equipment (DME)

  • Definition

    • DME refers to medical equipment that is rented and can be reused.

    • Common items include:

      • Crutches

      • Wheelchairs

      • Walkers

      • Hospital beds

      • Ventilators

      • Oxygen equipment

  • Such equipment can be billed under durable medical equipment codes (HCPCS).

Insurance Documentation

  • Explanation of Benefits (EOB)

    • Sent to patients to explain what has been covered by insurance, including deductible and out-of-pocket costs.

  • Remittance Advice

    • Sent to healthcare providers detailing accepted or rejected claims and the reasons for denial, occasionally requiring recoding.

Advanced Beneficiary Notice (ABN)

  • Purpose

    • A form signed by patients receiving procedures not typically covered by Medicare or Medicaid, indicating financial responsibility if the procedure is not covered.

Health Maintenance Organization (HMO) vs. Preferred Provider Organization (PPO)

  • HMO

    • Requires patients to choose a primary care physician and obtain referrals for specialists.

  • PPO

    • Allows more freedom to see any specialist without a referral and typically covers care within a network of preferred providers.

Preauthorization

  • Definition

    • Refers to approval from an insurance company before certain procedures, particularly elective surgeries, are carried out to ensure coverage.

    • Not needed in emergency situations.

Medicare vs. Medicaid

  • Medicare

    • Primarily for individuals 65 years and older.

    • Has four parts:

      • A: Hospital coverage

      • B: Doctor's visits and DME

      • C: Supplemental plans

      • D: Prescription drug coverage.

  • Medicaid

    • Designed for low-income individuals and families.

Medical Assistance Limitations

  • Restrictions for Medical Assistants

    • Cannot diagnose, prescribe drugs, or order laboratory tests and diagnostic imaging.

    • Can reinforce patient teaching but not provide medical advice.

Legal Aspects

  • Assault and Malpractice

    • A medical provider can be charged with assault if a procedure is performed without patient consent.

    • Malpractice involves a provider doing something they know is wrong, leading to patient harm.

Chain of Custody

  • Importance

    • For tests that have legal ramifications (like drug testing), chain of custody ensures the specimen has remained uncontaminated and secured.

    • Key steps include sealing the specimen in front of the patient and verifying temperature to prevent fraud.

Clinical Laboratory Improvement Amendments (CLIA)

  • Definition

    • Regulations overseeing laboratory testing to ensure accuracy and reliability.

    • Examples of CLIA-waived tests include:

      • Home pregnancy tests

      • Strep tests

      • COVID swabs.

Safety Protocols

  • Control and Prevention

    • OSHA: Regulates workplace safety.

    • CDC: Focuses on disease prevention through guidelines and vaccinations.

    • Standard precautions must be followed with all patients to prevent infection transmission.

Patient Identification

  • Verification Process

    • Always use two identifiers (name and date of birth) rather than implying patient identity.

Consent Types

  • Implied Consent

    • Demonstrated by a patient’s actions, like rolling up a sleeve for blood drawn.

  • Informed Consent

    • Must be provided by the physician detailing the procedure and risks, which the patient signs to show understanding.

Patient Scheduling Techniques

  • Wave Scheduling

    • Multiple patients scheduled at the same time to fill available slots and manage wait times.

  • Cluster Scheduling

    • Patients with similar issues are scheduled together for efficiency.

Patient-Centered Medical Home (PCMH)

  • Definition

    • A holistic approach that centers around all aspects of a patient's well-being, medical and social.

Basic Patient Care Techniques

  • CAPR

    • Compression to ventilation ratio for CPR is 30:2, with normal chest compressions at a rate of 100-120 compressions per minute.

Laboratory Procedures

  • Blood Draw Order of Tubes

    • 1. Yellow (blood cultures)

    • 2. Light Blue (coagulation studies)

    • 3. Red (non-additive)

    • 4. Gold/Green (chemistry)

    • 5. Lavender (hematology, EDTA)

    • 6. Gray (glucose).

    • Hematocrit and Hemoglobin: Normal values are 45% (hematocrit) and 15 g/dL (hemoglobin), with lower values indicating anemia (symptoms include dizziness, cold intolerance).

Compliance Procedures

  • Phlebotomy Techniques

    • Tourniquet should be placed 3 inches above the site.

    • Venipuncture angle should be 15 degrees; no longer than one minute with a tourniquet.

    • Hematoma is a common complication; should use proper technique to minimize risks.

Infection Control in Procedures

  • Aseptic Technique

    • Levels: Sanitation (hand washing), Disinfection (equipment cleaning), Sterilization (surgery preparation).

    • Use chlorhexidine or iodine for surgical prep, with iodine avoided in known allergic reactions.

    • Always don PPE correctly, removing the gloves first and then the gown, following the correct order to prevent contamination.