Module 15: Administrative Assisting

Question 1

Schedule Matrix

Answer 1

Flat, two-dimensional table that shows relationships between dates, activities, and human resources which are planned ahead by an associate schedule

Question 2

Wave scheduling

Answer 2

Allows three patients to be scheduled at the same time, to be seen in the order in which they arrive. Allows one patient arriving late to not disrupt the provider’s schedule

Question 3

Modified wave scheduling

Answer 3

Allocates two patients to arrive at a specified time and the third to arrive approximately 30 minutes later. Sequence is continuous throughout the day

Question 4

Double-booking

Answer 4

Two patients are scheduled at the same time to see the same provider. Used to work in a patient with an acute illness when no other time is available. Creates delays in the provider’s schedule that continues through the rest of the day

Question 5

Information necessary to schedule an internal appointment with an established patient

Answer 5

Name, DOB, reason for visit, time the patient and provider will need for the visit, preference for day of the week or time

Question 6

Notice of privacy practice

Answer 6

HIPPA mandated, describes how your medical information may be used and disclosed

Question 7

Purpose of documenting cancellations and no-shows

Answer 7

To protect the provider from legal action and demonstrate noncompliance

Question 8

Filing systems: conditioning

Answer 8

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

Question 9

Filing systems: releasing

Answer 9

marking the form to be filed with a mark of designated preference (ready to be filed, provider’s initials, using a stamp)

Question 10

Filing systems: indexing and coding

Answer 10

determining where to place the original record in the file and whether it needs to be cross referenced in another section

Question 11

Filing systems: sorting

Answer 11

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

Question 12

Filing systems: storing and filing

Answer 12

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

Question 13

Filing systems: alphabetic filing

Answer 13

Files are arranged by last name, first name, and middle initial

Question 14

Filing systems: numeric filing

Answer 14

Typically combined with color coding, used for larger health centers or hospitals. Allows for unlimited expansion without the need to shift files to create room. Saves time for retrieving and filing charts and provides additional patient confidentiality

Question 15

Filing systems: subject filing

Answer 15

Used for general correspondence using the alphabetic or alphanumeric filing method. All correspondence dealing with a particular subject is placed under a specific tab with subject headings

Question 16

Legal requirements maintenance, storage, destruction of medical records

Answer 16

Charts should never leave the office.
Transcription should be processed in a timely manner, documents that have yet to be filed should be locked away at closing.
Prescription pads should be kept in a locked, tamper-proof safe.
Any patient covered by medicare or medicaid must have their records retained for a minimum of 10 years.
HIPPA does not require a specific method for disposal, but it should be professional and confidential document destruction service

Question 17

CPOE

Answer 17

Computerized physician order entry. Created to improve the safety of medication orders, but now allows providers to digitally order laboratory and radiology testing, treatments, referrals, and prescriptions

Question 18

How to handle requests for medical records

Answer 18

All requests need to be provided in writing and release filed into patient’s chart.

The patients attorney, mediator, etc. must obtain approval from the patient, unless a legal power of attorney document authorizes otherwise

Question 19

Copay

Answer 19

Specified sum of money based on the patient’s insurance policy benefits at the time of service

Question 20

Coinsurance

Answer 20

An amount a policyholder is financially responsible for according to their insurance. Ex: Must meet a specified deductible amount before the medical insurance company will contribute their portion. Typically 80/20 ratio

Question 21

Deductibles

Answer 21

Specific amounts of money a patient must pay out of pocket before the insurance carrier begins paying for services

Question 22

Explanation of benefits

Answer 22

Provided to the patient by the insurance company as a statement detailing what services were paid, denied, or reduced in payment. Also explains amounts applied to deductible, coinsurance, or allowed amounts.
Sent to the patient after the claim has been processed

Question 23

Remittance advice

Answer 23

Explanation of benefits sent to the provider from the insurance carrier, includes electronic fund transfer information. Used to post payments to patient accounts

Question 24

Advance beneficiary notice

Answer 24

Form a medicare patient will sign when the provider thinks Medicare might not pay for a specific service or item. An official payment decision is made and a Medicare Summary Notice sent to the patient with an explanation for noncoverage; expectation that the patient will have to pay for services

Question 25

Federal policy insurance plans

Answer 25

Tricare (military and dependents).

Medicaid is funded by those who meet specific criteria

Medicare is for those 65 and older or the disabled

Workers comp is a state law that protects employees against the cost of work-related injury

Question 26

Private policy insurance plan

Answer 26

Include group policies offered through employer, individual policies are those that an individual funds themselves. Patients might pay entire premium themselves if self-employed

Question 27

Information needed to verify insurance

Answer 27

Patient’s full name, DOB, Policy number, SS number (depending)

Question 28

Indigent program

Answer 28

charity care programs that offer free or low-cost treatment for those who can’t pay

Question 29

ICD-10-CM vs ICD-10-PCS

Answer 29

ICD-10-PCS is for procedural codes in hospital settings, while ICD-10-CM is for procedure codes in clinical and outpatient settings.

ICD-10 codes represent patient diagnoses

Question 30

CPT codes and modifiers

Answer 30

Current Procedural Terminology codes and modifiers are used to document procedures and technical services based on services by providers in outpatient settings.
All information in medical record must be accurate.
CPT codes identify services rendered rather than patient diagnoses

Question 31

HCPCS codes

Answer 31

Healthcare Common Procedure Coding System is a group of codes and descriptions that represent procedures, supplies, products, and services not covered or included to the CPT coding system.
Updated every year like CPT codes.
Designed to enhance uniform reporting and collection of statistical date on medical supplies, products, services, and procedures. Typically used for Medicare and Medicaid insurance plans

Question 32

Forms used to obtain information necessary to send out claim

Answer 32

Patient encounter form, treatment or progress notes, history and physical exam notes, discharge summaries; operative report or pathology report if surgery or lab services

Question 33

CMS-1500 form requirements, responsibilities of a medical assistant (billing)

Answer 33

1) All new patients need to fill out a registration form with demographic and insurance information.
Insurance information needs to be verified for eligibility and specific requirements.
2) Determine whether patient requires an authorization or referral from the insurance carrier.
3) Review patient medical records for accurate documentation for the visit.
4) Encounter form / superbill from provider will determine the correct procedural code and diagnoses. Review the medical documentation to substantiate the correct charges and confirm accurate diagnoses are used for each procedure.
5) Send the claim to the insurance company for reimbursement and services rendered

Question 34

Proper formatting for insurance claims

Answer 34

If paper, needs to be manually filled out and mailed to insurance company.
Clear and concise, formatted correctly, all uppercase, no punctuation included, nothing photocopied, nothing handwritten, no staples.
Usually sent electronically through direct billing system or clearinghouse vendor

Question 35

Definition of chart reviews; purpose for billing

Answer 35

Collection and clinical review of medical records to ensure that payment is made only for services that meet all plan coverage and medical necessity requirements. Insurance companies will review charts to reduce payment or billing errors or documentation issues

Question 36

E/M services acronym

Answer 36

Evaluation and management; E/M coding involves translating the encounters into CPT codes to facilitate billing

Question 37

Three factors in determining level of service with E/M coding

Answer 37

History, Examination, and Medical decision making

Provider will document whether the patient has a problem-focused, detailed, or comprehensive history.
Provider will document their examination of the patient regarding specific body areas and organs systems, as well as level of examination provided.
Provider will document place of service and patient status.

The level of E/M service code must be documented with full detail in patient’s medical record and noted on the encounter form for billing procedures

Question 38

When should a referral be submitted?

Answer 38

After approval of the provider and authorization from the insurance company has been obtained

Question 39

Types of referral

Answer 39

Regular (3-10 business days)
Urgent (24 hours)
Stat (as quickly as possible) - sometimes additional information is required

Question 40

Information to include in a patient referral

Answer 40

Demographic and insurance information, provider’s identification information (including National Provider Identification (NPI)), diagnosis, planned procedure or treatment

Question 41

Preauthorization

Answer 41

A process required by some insurance carriers in which the provider obtains permission to perform specific procedures or services or refers a patient to a specialist.
Most managed care and HMO insurances require preauthorization.
Financial obligations are typically higher, and the patient should be aware of covered and noncovered benefits.
Services typically for nonemergent surgeries, expensive tests, medication therapies

Question 42

What to include when obtaining or verifying prior authorization?

Answer 42

Authorization code, date it is effective and it expires
Authorized diagnosis and procedural codes
Contact information for the specialist office
How many visits are authorized
What the authorization has been issued for

Question 43

Precertification

Answer 43

Process required by some insurance carries in which the provider must prove medical necessity before performing a procedure. Also sometimes required for specific types of lab tests, diagnostic tests, and unusual or expensive procedures.
Most insurance companies require precertification within 24 hours of admission

Question 44

Participating providers

Answer 44

Agree to adjust the difference between the amount charged and the approved contracted amount the insurance company will reimburse you

Question 45

Account balance

Answer 45

Total balance on an account; can be a debit (negative) or a credit (positive)

Question 46

Accounts receivable

Answer 46

The amount owed to the provider for the services rendered

Question 47

Accounts payable

Answer 47

Debt incurred but not yet paid; can be for supplies or utilites

Question 48

Assets

Answer 48

Property of an individual or organization that is subject to payments for debts owed

Question 49

Liabilities

Answer 49

Items that are outstanding (debts)

Question 50

Requirements for credit arrangements

Answer 50

Medical assistant must provide a detailed explanation of fees, services, and charges, as well as convey a tactful and courteous explanation of the payment plan.
Discussion of payment info must be documented and signed by an authorized member of the office and the patient, this documentation must be attached to the patient’s financial record with a copy given to the patient.

The medical office has the right to charge additional fees if a check is returned to the medical office for nonsufficient funds

Question 51

Process of charge reconciliation

Answer 51

1: adding deposits; deducting outstanding checks, bank service charges, NSF checks and fees, and check-printing charges
2: adding the interest earned along with any notes receivables collected by the bank
3: Make sure the bank statement and office accounts match
4: Compare the adjusted balances and record all adjustments to reconcile the balance, this confirms the accounts are accurate

Question 52

Running an aging report (collections)

Answer 52

Necessary before submitting any account to collection. Aging reports are grouped by day of last payment. Generally the assistant makes a reminder call, letters, etc.
When the final notice is sent the account must be sent to collections and all further patient contact regarding the account must be discontinued.
Always treat the patient with respect

Question 53

Steps to appeal a denial

Answer 53

1) determine why the claim is denied
2) obtain and complete the insurance company’s appeal document as quickly as possible
3) Include a letter from the provider to provide support for medical necessity, progress notes from the treating provider, and relevant results from any testing performed

Question 54

EMR vs EHR

Answer 54

EMR are electronic medical records; digital charts. They can be created and maintained by those within a single health care organization.

EHR are electronic health records, include the EHR and other information to be used between facilities