=AMCA American Medical Certification Association Medical Administrative Assistant Certification (MAAC) Study Guide This documents the property of the ‘American Medical Certification Association (AMA). This cannot be reproduced for any reason without the written consent from the ‘AMCA. 1 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018Dear Student, This exam prep study guide is intended to be used as reinforcement for what you have already learned. It is not intended to replace classroom learning or notes that you have already taken. Instead, use what you have already learned, and the notes that you have taken and the books that you used could be a great reference while you are studying. The exam consists of 100 multiple choice questions and you will have 2 hours in which to complete the exam. When taking the test, always apply these test taking strategies: '* Look for distracters in the question such as the words, not, always, exactly, first, next, ete. © Read all the answers * Eliminate the ones that you know are incorrect * Narrow it down to 2 possible answers ‘© Choose the BEST possible answer ON TEST DAY 1. Please bring a picture ID with you. A valid driver’s license, county 1D, and passport are all acceptable forms of 1D. 2. Please bring a #2 pencil with you. 3. Fill out all registration and test answer sheets in their entirety. Your full name as you ‘would like it to appear on your certification card, your complete SSN and mailing address are necessary. Failure to provide this information, will delay the processing of your exam, 4. DO NOT WRITE IN THE TEST BOOKLET! All of your answers must be recorded on the answer sheet. 5. Cheating of any kind will not be tolerated. If someone is suspected of cheating, they will be removed from the classroom. They will forfeit their right to retake the exam. 6. In order to be successful on the exam, you must achieve a 67% or better on the exam, Once the exam begins, you will nat be allowed to access your cell phone or any other electronic device. Please turn them to silent prior to entering the classroom. 8. Once the exam begins, you will not be allowed to use the restroom, Please use the restroom before the exam begins. Special Accommodations 2AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018AMCA pledges to comply with the provisions of the Americans with Disabilities Act. as amended (42 USCG Section 12101, et. seq.), and with Title VIl of the Civil Rights Act, as amended (42 U.S.C. 20006, et seq,), to the best of their ability. If you need special accommodations because of a disabling condition, you may ask for special testing services. This request must be submitted in writing and included with your registration, All requests are handled on an individual ba: IF you are requesting special accommodations you must submit a letter (IEP) from an appropriate healthcare professional that is licensed to evaluate the disability. The letter must be written on the healthcare professionat’s letterhead and include the professional's title, address and telephone number and date. The letter must also include a diagnosis of the disabling condition and explain why special testing accommodations are necessary, The letter must have an original signature from the professional and be dated no more than 2 years prior to registration of the exam Exam Challenges 'F you have a question or believe any part of the exam was unfair or misleading, you can email ‘customer service and your concerns will be forwarded to the appropriate department. When emailing, please include “Exam Challenge” in the subject line and email to: amca@AMCAexams.com| 3 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018Introduction The medical administrative assistant is an essential role that is necessary for a smooth, productive environment within a medical facility. Since the medical administrative assistant is often the first point of contact, both over the phone and in person, it is essential to maintain a professional demeanor at all times. The medical administrative assistant is responsible for a wide array of duties which include phone reception, patient scheduling, collecting payments, and maintaining patient files. in addition to knowledge and skill, the successful medical administrative assistant should have a pleasant personality, strong communication skills anda good work ethic, Loyalty or faithfulness to a cause is a good characteristic to portray as well as being flexible in order to adapt to various situations. Medical Law & Ethics The medical administrative assistant should have a basic understanding of various concepts regarding medical law. The law requires each patient to provide consent before they are examined or treated by 2 physician or healthcare provider. This method is often known as expressed consent, in which a patient acknowledges that they have received proper direction regarding the nature of their medical treatment. Expressed consent can be communicated via verbal communication or through the action of signing a consent form. Implied consent is given when a patient uses body language to indicate that they agree to receive a form of medical care. This type of consent is communicated through an act such as a patient silently rolling up their sleeve to give a blood sample. {tis essential to demonstrate skill and accuracy at all times. If you are unsure of what to doin a situation, the best thing to do is simply wait until you have received proper direction. Mistakes made by the medical administrative assistant, and other members of the medical staff can result in a lawsuit flled against the physician who owns the medical facility. This is known as the doctrine of respondeat superior, a Latin term which means “Let the master answer.” The medical administrative assistant will spend a large amount of time dealing with patient records. It is necessary to take the proper precautions when dealing with requests that are made regarding the patient's medical records. In the event that someone, other than the patient, requests a copy of a medical record, it is necessary to verify that the patient has authorized the release of their information with a signature. Before releasing a copy of a ‘medical record, the medical administrative should review the file to ensure that it does not ‘contain any information regarding another patient. The only time a file can be released is when a court requests it by means of a subpoena, It is essential for the medical administrative assistant to familiarize themselves with the concepts of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA requires the Usage of password protection on all electronic devices used to access patient information. If you work in a reception area that is visible to patients, it is important that your computer is positioned in a manner that does not reveal information to patients that may be standing close to your desk. Equally important is that if the reception area has a sliding glass window in which to greet/communicate with patients, this window should remain closed for an extra layer of 4 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018Privacy. Additionally, each employee is required to log off of their computers when leaving their desks, in order to prevent information from falling into the wrong hands. Phone Etiquette ‘When speaking on the phone always identify yourself to the caller. Convey to the person your undivided attention and willingness to help. Listen without interrupting, provide reasonable alternatives for the caller and take a clear concise message in order for the call to be returned The following steps will ensure proper telephone etiquette: ‘* Answer the telephone promptly and kindly. © Never allow an angry or aggressive caller to upset you; remain calm and composed © Speak clearly and concisely mn before placing them on hold ‘© Be sure to ask the caller’s permis: Understanding a patient’s feeling is important. They may be anxious, nervous or even frightened. Empathy, having an understanding and compassion for what they may be experiencing, is a good characteristic to have in order to relate to your patients. E-mail is a quick and easy way to communicate. This could be considered an informal type of communication, but in some situations could be used for legal purposes. Keep these handy tips in mind when using email to communicate '* Use a personal name if your system allows it ® Fillin the subject line to identify your message. ‘® Donot write a message with upper case as this may be perceived as expressing anger. '* ALWAYS CHECK WHO THE RECEIVER OF THE EMAIL IS BEFORE YOU CLICK SEND. This can be quite embarrassing if the email goes to the wrong recipient. * Use “please” and “thank you”. ® Remember, email could be used as a legal document. Never threaten or intimidate someone; even in jest, When communicating with patients/clients all types of communication should always be professional. Asking for feedback when communicating with patients lets everyone involved understand whether or not the message given is received. The principal message you are giving a patient if you avoid eye contact is that you are not being truthful. Verbal body language, such asa nod of the head, is also a way of providing feedback. n & Regist The medical administrative assistant’s duties begin before the patient has entered the office. If you are new to the position, the best way to learn what your duties will be is to ask for a job description and clear directions for daily activities. Each facility will have its own policy, however the medical administrative assistant will usually be responsible for preparing files either the night before or the morning of the day the patients are scheduled to arrive. Ifa new patientis Patient Recey Qn 5 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018expected, all the appropriate paperwork must be included in their fil. If an established patient Is expected, up to date information regarding previous laboratory result reports, pathology reports, or similar documents must be included in the file. Greeting the Patient ‘A successful medical administrative assistant will be able to juggle the responsibilities of answering phones, completing paperwork, and greeting patients in a proper manner. If a patient arrives while the medical assistant is handling a phone call, the proper action is to look up and smile at the patient, then hold up an index finger to indicate that you will be able to assist them shortly- asking the person on the phone to hold is also acceptable. if the medical assistant is available, the patient must be greeted in a friendly manner, and then handled according to their status. For new patients, instructions should be given regarding the completion of paperwork, and the patient should be oriented with the facility including the location of the restroom, refreshments, and appropriate places to hang their coats, umbrellas etc. Established patients must provide confirmation of the accuracy of information including their address, telephone number, insurance carrier, or any other information that must be kept up to date. If it is necessary to discuss confidential information regarding the patient's finances or health information, the medical assistant should ensure that the patient is out of the hearing range of other patients. In order to remain compliant with HIPAA standards, the sign-in sheet must be set up in a way which prevents a patient from seeing the signature of the previous patient, Collecting Payments The certified specialist is cesponsible for the collection of copayments which will typically occur when the patient arrives to register at the reception area. In order to save time and ensure accuracy, the amount required for co-pay should be listed in the patient’s file. Each medical facility should always call and verify each patient’s insurance information/eligibility. When verifying the patient's eligibility, always ask what the patient’s copayment is. Each facility will have its own method of dealing with patients that are unable to provide payment at the time of their appointment; however it is the medical assistant’s responsibility to handle this situation in a pleasant, considerate manner. The patient aging report is used to collect overdue accounts from patients. During collections, most practices use letters and calls to attempt to get payment from overdue accounts. if collecting a debt over the phone, only speak to the patient who is responsible and listed on the account. The day sheet produced by the practice management program shows the payments and charges that occurred on that date. Most facilities use preprinted fee slips, also known as superbills, to track fees for each patient. Either the physician or medical assistant will use the fee slip to make note of the services or procedures that were performed, in addition to any diagnoses assigned to the patient. Since procedural and diagnosis codes change every year, fee slips should be reviewed for accuracy on an annual basis to determine if they need to be reprinted. 6 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018The Assignment of Benefits statement must be kept on file which authorizes the provider to be paid by the patient's insurance company. ‘Acknowledging the Notice of Privacy Practices is also kept on file assuring that the patient has read and understands how the provider will keep the patient's information private. ‘Scheduling The medical assistant is responsible to schedule patients in a manner that is both accurate and effective. Typically, a physician may spend more time with a new patient versus an established patient. Each facility will have different policies however; a physician's preferences are a priority. istablished Patients New When scheduling patients, it is essential to accurately determine whether they are new or established patients. Generally speaking, a new patient has not received care from any of the health care providers of the same specialty within the previous 3 years. An established patient has received care from one of the health care providers of the same specialty in a medical office within the previous 3 years. A facility may require an established patient to be considered as a new patient if the patient has received major injuries due to a car accident, job-related incident, or any other accident. The medical assistant should familiarize themselves with policies regarding new and established patients. When scheduling a new patient, itis essential for the medical assistant to collect the following information: © Provider and type of appointment ‘© Correct spelling of patient’s full name * Patient’s address ‘* Appropriate telephone number © Reason for visit ‘© Name of referring physician, if available Type of insurance ‘Types of Scheduling In most cases, one patient is scheduled for a specific appointment time, also known as fixed appointment scheduling. In the event that a group of patients are scheduled to come in to receive the same type of service, the medical assistant should schedule the patients around the same block of time, 2 method known as cluster scheduling. When two patients are scheduled to see the same physician at once, this method of scheduling is known as double booking. This type of scheduling is usually used to accommodate an emergency patient, or any other situations that may be determined at the physician or medical assistant’s discretion. Facilities that are able to accommodate a large amount of patients usually make use of the 7 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018wave scheduling method. When using this system, patients are scheduled for the first half of each hour, and each patient is seen in the order they arrive. If patients arrive at the same time, the medical assistant should prioritize the patients based on their medical needs, also known as 2 triage. Certain facilities will offer open hour, where patients are allowed to receive care on a walk-in basis, The matrix shows the time not available for scheduling. Reminders and No Shows Established patients are usually provided with appointment reminder cards after their appointment. The cards contain information such as the date and time of the patient's next appointment in addition to the name and telephone number of the office. Certain offices may choose to use a follow up phone call as a method of reminding patients of their upcoming appointments. These calls are usually made the night before the patient is scheduled to arrive, and will include specific information related to the patient's appointment. If it is necessary to leave a voicemail, itis essential to remember that the patient's information is confidential, and personal information must not be disclosed. Here is an example of an appropriate voicemail, "Good Evening. This is ___ calling from Dr. Allan's office to remind ___ of his/her appointment, tomorrow at 10 AM. Feel free to call us with any questions, the number is 973- 555-1234.” In the event that a patient fails to show up for an appointment without notifying the office, this is considered a “no show” Typically, no shows must be contacted in order to determine whether they would like to reschedule. The missed appointment, as well as any information regarding attempts made to reschedule must be documented in the patient's file. Office Communication Office communication is a very important part of the everyday functions in any type of setting. The office policy manual contains regulations for personal appearance as well as protocols for computer use, PTO, and office behaviors. Office memos will often be 2 requirement of the medical administrative assistant. Depending on the preference of the physician, the standard elements in a memo include: a heading, a date, to, from, subject, body and copy. If you are required to make a block style letter, the inside address is flush left as well as the body copy. An inside address includes the name and address of the person receiving the letter. A full blockis a business letter in which all information starts at the left margin on the page. The medical administrative assistant may be issued petty cash. This is money used for office supplies, like paper towels, staples, paper and various other materials needed to make the office run smoothly. Me Proper maintenance of medical records is an essential aspect of any effective medical facility Medical records include information used for personal identification such as name, birth, gender, marital status, and occupation. When making entries into a medical record, all entries should be initialed by the person making the entry. A patient's medical record will also contain | Records BAMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018financial information regarding their insurance such as policy/identification numbers and documentation regarding correspondence with the insurance company. Information regarding, the patient’s medical history, laboratory results, prescriptions or any other medical information is an essential part of a patient’s medical record. The medical assistant must ensure that each part of the patient's medical record is accurate, and up to date. Not only is this information ‘essential in the process of deciding an appropriate method of care for the patient, they are necessary in the event that a patient’s records are required for a legal matter. A patient's medical record cannot be released without a patient's signed consent. Medical records are often used to determine whether the requirements for a standard of care have been satisfied. Legally, a standard of care requires a health care provider to use the same skill to treat a patient, as another provider with equivalent training would use in the same situation. Charting When physicians dictate notes about patient care, then have those notes transcribed and placed in the patient's files, this method of charting is known as the narrative style. ‘Another method of adding information to @ patient’s medical record is known as SOAP note ‘charting. SOAP is an acronym that stands for subjective, objective, assessment, and plan. Any information that the patient provides including a chief complaint, or comments made during an ‘examination are considered subjective information. information based on observations made by the physician or medical assistant are considered objective. This may include laboratory results or vital signs. An assessment is a brief summary of the patient's symptoms, and may often include a diagnosis as well as a list of other possible diagnoses, usually in order of most likely to least likely. A plan consists of any information regarding the prescribed plan of action for a patient, such as prescriptions, instructions, or referrals. Problem-oriented medical record charting, also known as POMR, is a method of tracking the patient's problems during the time they are receiving medical care. This method requires that a number be assigned to any of the patient’s problems, this number will be referenced each time the patient comes in to receive care. Each medical problem, and its assigned number, will have its own chart in the patient’s medical record, for easy access in the future. ‘A flow chart is a visual aid used to keep track of information over a period of time. Flow charts may be used to record information such as measurements of weight, length, or head circumference for infants. Progress notes are daily chart notes which are used to record any information that pertains to the various stages of a patient's condition. This form of charting will include information such as the initial condition of the patient, recommended treatments, and outcomes (if there are any). Generally speaking, medical practices often use either the alphabetic or numeric system to file information. When using the alphabetic filing system, information is filed according to the patient's last name. When forms are filed in chronological date order, the forms are read almost 9 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018like a diary. A chronological file used as a reminder is called a tickler file. Confusion may arise when a patient has a hyphenated last name such as Lewis-Davidson. In this situation, it may be beneficial to make use of a practice that is known as cross-referencing. In this situation, the file for the patient with the last name Lewis-Davidson, would be filed under the patient's full last name. A separate, blank file containing any possible combinations of the name would be filed in ‘two separate additional places: Lewis and Davidson. In the event that the patient (whose last name is Lewis-Davidson) called and identified themselves under one name (Lewis or Davidson), the medical assistant would look in either the Lewis or Davison file and find a blank file directing, them to the appropriate folder (Lewis-Davidson). ‘When using the numeric filing system, information regarding each patient is stored using @ number, instead of the patient's last name, a method which helps to mask the patient's identity This method of filing is used in medical practices which deal with highly sensitive information such as an HIV/AIDS clinic, or drug/alcohol rehabilitation centers. 1 Records Electronic Medi ‘An important business document, a medical record is used to support treatment decisions, document services provided, and could also be used in a court of law for evidence purposes. Electronic Medical Records (EMR) are computerized records of one physician's encounter with 2 patient over time. The EMR reflects treatment of a patient by one physician. In contrast an Electronic Health Record (EHR) reflects the data from all sources that have treated the individual. Personal Health Record (PHR) are maintained and owned by the patient. The patient makes the decision whether to share the contents with their physician. The contents of a health record vary depending on the setting. Acute care, most often refers to @ hospital, treats patients with urgent problems that cannot be handled. Ambulatory care refers to treatment without admission to hospital. Hospital records keep track of time-limited episodes where doctor charts are reflective of the ongoing health of individuals. ‘Advantages of Electronic Health Records Safety © Quality of care © Efficiency © Cost Reduction HIPAA Security Rules HIPAA requires the usage of password protection on all electronic devices used to access patient information. If you work in a reception area that is visible to patients, it is important that your computer is positioned in a manner that does not reveal information to patients that may be standing close to your desk. Any information given by a patient to medical personnel that cannot be disclosed is known as privileged communication. Additionally, each employee is required to log off of their computers when leaving their desks, in order to prevent information from falling into the wrong hands. 10 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018Encryption is also required when computers exchange data over the Internet. Encryption is the process of encoding information in such a way that only the person (or computer) with the key can decode it. PMP’s encrypt data traveling between the office and the Internet, especially numbers. Direct data entry, direct transmission, and clearinghouses are common methods of transmitting HIPAA claims ~ a fax would not be considered secure and therefore is not recommended. Encounter Forms This form is completed soon after a visit by a provider to summarize billing information regarding the visit. Preauthorization ‘A managed care provider often requires preauthorization before the patient sees a specialist. If the payer approves the service, it issues a pre-authorization number that must be entered on in the practice management system so it appears later on the healthcare claim for the encounter. The pre-authorization number may also be called a certification number. Often times, patient's need to see another doctor in addition to their primary. Referrals, a written request for medical services, describe the services the patient is to receive. With each insurance plan, referrals operate differently, so it is always best to check with the patient's insurance provider before scheduling the appointment. Insurance Plans The primary insurance is the one who pays first. The secondary insurance can provide benefits once the primary insurance has already paid. Tertiary insurance is a third payer and will pay after the first and second insurances have paid. Supplemental insurance can cover services not normally covered by a primary plan. All insurance plans have a COB ~ a coordination of benefits = which indicates how a policy will pay when more than one insurance plan is in effect. HIPAA COB number is X12837. The COB information is exchanged between health plan and provider or between a health plan and another provider such as home owners insurance. If a health plan member receives medical services from a provider who does not participate in the plan, the cost for the member is typically higher. Verification of insurance benefits is usually done by calling the insurance carrer. 11 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018How to determine who has the primary coverage? Patient has one policy Patient is covered under two group plans Patient is covered under a group plan and an individual plan Patient is covered as a dependent under another insurance policy Patient is covered under an employer plan and a government sponsored plan Patient is retired and covered by a spouse's plan that is stil working, even though the retired patient has Medicare. Patient sa dependent covered by both parents; the birthday rule is in effect. If two or more plans cover dependent children of separated or divorced parents Primary Plan that has been effect for the longest period of time is the primary, unless that ‘employee has been laid-off or retired, tthe original plan in existence is then the primary, Group plan is the primary Patient's plan is the primary Employer plan is the primary ‘Spouse's plan is the primary ‘The Birthday Rule determines the primary insurance by whose birthday comes first 11 The primary is typically the custodial parent 2 The plan of the spouse of the custodial parent if remarried 3 The plan of the parent without custody (IN THIS ORDER) Main Terms, Sub terms, and Nonessential Modifiers Each main term appears in boldface and is followed by th are any subterms associated with the main term. Subterms are impor e default code. Below the main term tant as they may show the etiology of the disease. Nonessential modifiers are shown in parentheses on the same line, ‘Common Necessary Terms to Coding 12 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018Eponym — Condition named for a person ~ such as Hodgkin's disease NEC - Not Elsewhere Classifiable ~ no code is specific for that condition NOS - Not Otherwise Specified — used when a condition is not completely described in the medical record. Code Also - may be found in the instructional notes indicating that a second code may be required Category - Three character alphanumeric code that covers a single disease or related condition Sub category — Four or five character alphanumeric subdivision of a category. Inclusion notes ~ Headed by the word “includes” and refine the content of the category appearing above them. Exclusion notes - Headed by the word “excludes” and indicates conditions that are not classifiable to the preceding code. © Excludes 1 is used when two conditions could not exist together © Excludes 2 means “not included here” but a patient could have both conditions at the same time. Punctuation © {}Brackets (square) enclose synonyms, alternative wording or explanatory phrases. Brackets identify manifestation codes. © () Parentheses are used in both the index and tabular list to enclose supplementary words ~ non-essential modifiers (© :Colons are used in the Tabular List after an incomplete term which needs one or more of the modifiers Sequelae ~ Are conditions that remain after a patient's acute illness or injury has ended ~ could be called residual effects or late effects. A late effect could be documented by the se of the expression due to an old...due to a previous. A good example of this, would be a deviated septum due to a nasal fracture, Providers — physicians, hospitals and other suppliers that furnish care or supplies to Medicare patients are called providers. Beneficiary Pays: deductible, premiums, co-insurance (20%) non-covered services Medicare Pays: covered services (80%) Current Procedural Terminology (CPT) The Current Procedural Terminology (CPT) used by physicians and other healthcare providers. It is considered Level | of the HCPCS. The CPT is made up of the main text ~ sections of codes ~ followed by appendixes and an index. 13 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018There are three categories of CPT codes: ‘© Category I codes ~ have 5 digits. Each code has a descriptor, which is a brief explanation of the procedure Category Il codes — used to track performance measures for a medical goal such as, weight loss © Category Il codes - temporary codes for emerging technology, services, and procedures. CPT codes are updated annually on October 1 and remain in effect for products and services provided after January 1 of the following year. (© Evaluation and Management Codes 99201-99499 Codes 00100-01999 © Anesthesia © Surgery Codes 10021-69990 © Radiology Codes 70010-79999 © Pathology and Laboratory Codes 80047-89398 © Medicine Codes 90281-99607 ‘A code range is shown when more than one code applies to an entry. Two codes are separated byacomma. A modifier is a two digit number that may be attached to most five-digit procedure codes. Z codes are used to report encounters for circumstances other than a disease or injury in the ICD-10 CM. In selecting an E/M code the three key factors that need to be considered are history, examination and medical decision making ‘Symbols used in Coding © bullet (solid circle) indicates a new procedure code. The symbol appears next to the code only in the year that itis added A Atriangle indicates that the code’s descriptor has changed. The symbol appears next to the code only in the year that itis added. 4 Facing triangles (two triangles that face each other) enclose new or revised text other than the code’s descriptor + Aplus sign next to a code indicates an add-on code. © A butter inside a circe indicates that moderate sedation is part of the procedure. H The lightning bolt symbol is used with vaccine codes that have been submitted to the FDA for approval and are awaiting approval. Patient Examination and Documentation History is documented in the patient's medical file. History is typically taken by the assistant or the doctor and could be used as a reference for certain diseases or symptoms. There are 4 different types of histories that could be taken: 14 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018History of Present Illness — description of its development from the first sign or symptom that the patient experienced to the present time. ‘The abbreviation PFSH stands for the following: Past Medical History ~ the past history explains the patient's experiences with illnesses, injuries, and treatments in addition to operations, injuries and hospitalizations, It also covers current medications, allergies, immunization status and diet. Family History ~ reviews the medical history of the patient's family. Social History — patient's age, marital status, employment, alcohol consumption, smoking history, ete. History: Four elements of a history Chief complaint History of present illness Review of symptom Past, Family and or Social History History Levels Problem Focused Expanded problem focused Detailed Comprehensive Examination Levels Problem focused Expanded problem focused Detailed Comprehensive n Making Complexity Levels Medical Det Straightforward Low Moderate High Straightforward Minimal diagnosis Minimal risk Minimal complexity of data 15 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018B. Low * Limited diagnosis Lmited/low risk to patient © Limited data Moderate Multiple diagnoses ‘Moderate risk to the patient Moderate amount and complexity of data een High Extensive diagnoses High risk to patient Extensive amount and complexity of data “9 Coding Compliance Coding is the transformation of verbal description into numbers — it determines the reimbursement of medical fees. A payer's initial processing of a claim screens for basic errors in claim data or missing information. Claims can be denied for careless errors or for incorrect, diagnosis and procedure codes. Rejected claims result in delays in the payment process or even fines to the provider. Errors relating to the Coding Process include: ‘® Truncated coding — using diagnosis codes that are not as specific as possible Assumption coding - reporting items or services that are not actually documented © Altering documentation after services are reported ‘© Coding without documentation + Reporting services provided by unlicensed or unqualified clinical personnel * Coding a unilateral service twice instead of choosing the bilateral code © Not satisfying the conditions of coverage for a particular se ‘© Payers not complying with the required claim turnaround time to receive payments in a timely manner © Fraud would be intentionally upcoding in order to increase payment ‘Acute codes and chronic codes, each of which has a separate code should be listed as acute code, chronic code Codes that report more than one diagnosis with one code is @ combination code Unbundling should be avoided — this is when multiple codes are used to code a procedure when a single code should be used 16 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018‘There can also be errors related to the billing process which also will delay a claim. The most common ones are: © Billing non-covered services © Billing over limit services '* Upcoding using a procedure code that provides a higher reimbursement rate than the correct code © Downcoding - the documentation does not justify the level of service © Billing without signatures © Using outdated codes ‘A good way to avoid any of the above errors is to use modifiers appropriately, be clear on discounts to uninsured or low income patients, and maintain good documentation templates on your EHR, Type of Audits + Audits are done before claims submission to examine claims for accuracy and completeness. + External Audits ~ Private payers or government agencies review selected records of a practice for compliance. + Internal Audits ~ conducted by the medical office staff ora hired consultant + Retrospective audits ~ conducted after the claim has been send the remittance advice has been received. Currently, about half of the insured Americans have health insurance through a private or commercial insurance company. Usually this is through a group policy sponsored by one employer. Practice management software has simplified the insurance billing process. Once a patient has received services and fees are applied to the account, the software will use the information entered to prepare the claim. Once the claim is sent to the insurance company and ‘a payment returns, it will be applied to the patient's account. This is accomplished with posting payments system. Adjustments (amounts added to or taken away from the balance of an account) still may be necessary once payment has been received. Adjustments are often used to reflect contract amounts, credits, refunds, discounts, bad debt (uncollectible A/R), and corrections to erroneous entries. When amounts are removed from a balance, the adjustment is sometimes referred to as a write-off. A/R (Accounts receivable) is a record of all monies due to the practice. ‘There are two methods to determine rates to be paid to providers. The first method is charge — based and the second method is resource - base. Charge ~ based fees are established using the 17 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018fees of providers providing similar services. Resource ~ based takes into account three relative factors 1) how difficult i it for the provider to do the procedure, 2) how much office overhead is involved, and 3) the relative risk the procedure presents to the patient and the provider. Allowed charges is the amount the most the payer will pay any provider for the CPT code. HIPAA X12 837 Health Care Claim: Professional — may be called the 37P claim or the HIPAA claim ~ it is based on the CMS ~ 1500. The CMS 1500, the electronic HIPAA claim, is @ paper form. Diagnostic codes from the encounter form are necessary to fill out a CMS-1500. Block 1 is, the type of insurance coverage and the rest of the top blocks are personal identification for the patient. Box 21is used for Dx (Diagnosis) codes. Up to 12 diagnoses can be reported on the CIMS-1500. A clean claim is a claim that has no billing or coding errors. Clearing Houses ~ Edits and transmits batches of claims to insurance carriers Fee schedule ~ patient pays doctor for professional services performed from an established schedule of fees- Physicians establish a list of their usual fees for procedures and services they frequently perform. + Usual, Customary, and Reasonable (UCR) = Method based on individual docs charge profiles and customary charge screens for similar groupings of physicians within a geographic area with similar expertise = Usual - fee normally charged for a given service Customary ~ fee in the range of usual fees charged by physicians of similar training, and experience for same service within the same specific and limited socioeconomic area Reasonable - fee that meets both of above or is considered justifiable by responsible medical opinion considering special circumstances of the particular case in question Relative Value Studies (RVS) ~ a list of 5 digit procedure codes for services with unit values that indicate the value for each procedure + Capitation © Managed care plans that are prepaid per person per month regardless of how many times the patient is seen. A capitated payment is when a physician has a contract with an insurance company to be paid whether he sees the patient or not. + Precertification —_ Isthe service covered under patient's insurance plan? + Predetermination — How much will insurance pay or maximum dollar amount for this service? + Preauthorization = Isthe service medically necessary? Principal diagnosis — the condition or diagnosis that brought the patient into the facility 18 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018+ Referrals © Formal * Authorization request is required to determine medical necessity can be obtained via telephone, but usually mailed or faxed. Medical necessity is defined as services that are reasonable and necessary for the related diagnosis or treatment. ct + Simplified authorization form is completed and signed by doc and handed to pt. at time of referral certain services may require direct. * Verbal + Primary care doc telephones specialist and indicates approval © Self + Ptrefers himself MEDICAID: A federal program administrated by state government to provide medical assistance for low income people or people that cannot afford to pay their medical bills. Each state sets its ‘own guidelines for eligibility and services, there benefits and coverage may vary widely from state to state. Medicaid continued: © Eligibility * Low income, blind, disabled '* People with low income and few resources receive financial assistance under Temporary Assistance for Needy Families (TANF) they are eligible for this assistance for a 5 year period. 2 Ifa Medicaid recipient is classified as a “restricted status” they can only see a specific provider for treatment. Claim Submission + Photocopy front and back sides of the card. Check ext eligibility for the month of service each time the pt. comes in * Check to see if service needs prior authorization + Use of CMS-1500 form + Claims must be signed by physician and sent to a fiscal intermediary who contracts to pay claims or to local department of social services. tion date and © Time Limit © Varies by state © If itis submitted after time limit, claim can be reduced or rejected unless there is valid justification by state laws MEDICARE: Is @ 100 percent federally funded health plan that covers people who are sixty-five and over and those who are disabled or have permanent kidney failure (end-stage renal disease, or ESRD). MEDICARE PART A: bled. It covers so called the Hospital Insurance for the Aged and 19 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018,institutional providers for inpatient, hospice, home health services and services within the hospital. MEDICARE PART B: Referred to as the Supplementary Medical Insurance (SMI). Coverage is a supplement of Part A, which covers outpatient, services by physicians, durable medical equipment, clinical lab services and ambulatory surgical services. Medicare Part 8 is voluntary or optional. MEDICARE PART C: Medicare Managed Care Plans (formally Medicare Plus (+) was created to offer a # of healthcare services in addition to those available under Part A & Part B. The CMS contracts with managed care plans or PPO’s to provide Medicare Benefits. MEDICARE PART D: Prescription Drugs enacted by the Medicare Prescription Drug, Improvement and Modernization Act in Dec 2003 and began implementation in Jan 2006 where Medicare beneficiaries have the choice of among several plans that offer drug coverage for which they pay a monthly premium. Medicare (overview) — Funded by federal government and administered by CMS = Atthe time of enrollment, a choice must be made about how the health care coverage is developed — Original medical plan is a fee for service ~ You can get a senior advantage plan from another carrier — Eligibility ‘© Application made through Social Security administration = Age 65 © Blind or disabled Chronic or end-stage kidney disease * Kidney donors = Part A—Hospital Insurance Benefits @ Benefit period begins when pt. enters hospital and ends when pt. has not been a bed pt. in any hospital for 60 consecutive days. Pays for medications related to hospital stays, skilled nursing stays (unless you live there), and hospice care — Part B~ Supplementary (Outpatient) * Premiums are paid by monthly deductions from Social Security checks Patients not on Social Security pay premiums to Social Security ‘© Claims must be made by physician's office © Pt. canbe billed for non-covered services @ Covers medications that are administered by or under the supervision of physician in the physician’s office that cannot be self-administered; oral anti- cancer drugs, drugs by hemodialysis facilities, outpatient facilities, etc — Part C- Managed Care ‘© Instead of Part A and Part B © Senior Advantage Plans ‘* Premiums similar to Medicare part B 20AMCA Medical Administrative Assistant Certification Suudy Guide (MAAC) 20182 Have to go to doctors, hospitals and other facilities on approved list ‘© Small co-pays © Another plan is Medical Savings Account (MSA) + High annual deductible for a catastrophic insurance policy approved by Medicare + Premiums are paid by pt. and deposits are made into the pts. MSA + Pays medical expenses until deductible is reached + Unused funds roll over to next calendar year — Part 0 ~ Prescription Drugs © Premium paid © Annual deductible not to exceed $250 and pay a cost sharing ‘Plan has a list of generic and brand name drugs that are allowed © Enrollment isn’t automatic unless patient is Medi-Medi * The “donut hole” is the amount of out-of-pocket costs after a certain amount of money has been spent from Medicare on prescription drugs ‘Required to cover vaccinations If patient is eligible and doesn’t enroll, late enrollment penalty will be applied that equals 49% per month — Participating Physician Accept assignment ‘+ Payment sent to physician — Nonparticipating Physician © Does not accept assignment * Payment sent to patient ‘Patient pays physician TRICARE = Dependents of military personnel = TRICARE Standard see claim form © Eligibility * Beneficiaries are spouse and unmarried children up to age 21 or 23if full-time students of active duty + Eligible children over 21 with disabilities + Uniformed service retirees and eligible family members + Un-remarried spouses and unmarried children of deceased, active, or retired service members © Defense Enrollment Eligibility Reporting System + Sponsor has to enroll family members + Providers call Voice response unit system © Benefits + Portion of civilian health care services cost pd by federal government + Patients usually seek care from military hospital near their home 21 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018+ Patient pays deductible for outpatient care and cost sharing percentages + If provider accepts assignment, he or she accepts allowable fee as full amount for services rendered + Nonparticipating providers must fle claims and may not charge more than 15% above maximum allowable charge for his services — Active duty military get treatment from a military treatment facility or hospital Unless it is unavailable and then the service member must get a non-availability statement (NAS) —_ Inan emergency, a soldier can get medical treatment and the military will pay CHAMPVA- Civilian Health and Medical Program for the Veterans Administration = Eligibility © Veterans and dependents (veteran must have total, permanent, or service-related disability) ‘® This is not an insurance program but a service benefit program © No contracts and no premiums © Beneficiaries can choose civilian health providers or military treatment providers. = Claims submission and time limit * 60 day time limit Workers’ Compensation + Illness or injury at work + Covers medical bills and lost wages Workers’ Compensation Laws + Mandatory in all states Types of disability — Non-disability ‘* Patient can still work = Temporary disability (TO) Patient cannot perform all functions of his or her job for a limited period of time ‘© Weekly benefits are based on employees earnings ~ Permanent disability (PD) © Injured worker is left with a residual disability © Sometimes patient can be rehabilitated in another line of work ‘* When a patient’s case becomes permanent and stationary and no further improvement is expected, the case is rated to the percentage of permanent disability and adjudicated so a monetary settlement can be made. = Reports + Initial report must be filed + Report from each subsequent visit must be filed = Highlights 22, AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018+ Workers comp has no deductible and no copayments. + Employer pays all premiums + All providers treating worker's comp patients must accept assignment and has to accept payment as payment in full + The patient must not be billed for services for any work related illness or Injury. Workers ‘Compensation Workers’ compensation is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee's right to sue his or her employer for the tort of negligence. The tradeoff between assured, limited coverage and lack of recourse outside the workers compensation system is known as “the compensation bargain”. ‘Workers Compensation is a contract between an employee and employer. While plans differ among jurisdictions, provision can be made for weekly payments in place of wages (Functioning in this case as a form of disability insurance), reimbursement or payment for medical health Insurance, and benefits payable to the dependents of workers killed during employment. The worker's compensation system is administered on a state-by state basis with a state governing board overseeing public/private combinations of worker's compensation systems. Vocational rehabilitation programs provide training in a different job for individuals with job- related disabilities. Health Insurance Terminology Allowed amount — this is the amount the insurance carrier is allowed to use to determine the amount for a service Co-insurance ~ calculated on a percentage of a charge Self insure - employers pay directly for employees’ medical bills Medicare ~a government program that provides insurance for persons over 65. © Medicare Part A— pays for inpatient hospital care Medicare Part B - Supplementary Medical Insurance helps pay for physician services - voluntary ‘Medicare Part C - offers Medicare beneficiaries Medicare Advantage plans that compete with the Original Medicare Plan Medicare Part D - provides voluntary Medicare prescription drug plans to those on Medicare 23 AMCA Medical Administrative Assistant Certfieation Study Guide (MAAC) 2018Medicaid — insurance for low income people — typically is the payer of last resort ‘TRICARE — insurance for active duty and retired service personnel and their families CHAMPVA - insurance for veteran's with service related disabilities Worker’s Compensation — provides coverage for employees for job-related illnesses or injuries Sliding Fee Scale - when offices charge fees based on a patient's financial ability to pay ‘Member/Subscriber/insured/ Policyholder - the person who owns the insurance policy Beneficiary — individuals who qualify for the program Dependents ~ family members (unmarried) covered by the insurance plan Premium — the policyholder contributes to his/her policy by paying a set amount of money Fee Schedule — physicians lists their charge for each service they provide Preferred Provider Organization - (PPO) patient pays an annual premium and often a deductible. Could have a low premium with a high deductible or vice versa. May see an out-of- network doctor without a referral or preauthorization, but the deductible may be higher. Health Maintenance Organization — (HMO) is licensed by the state. Stringent guidelines and a narrow choice of providers- typically need authorization before a procedure will be covered, ‘Members are assigned primary care physicians and must use network providers to be covered, except in emergencies. Treatment, Payment and Health Care Operations — TPO - Under the HIPAA privacy rule, providers do not need specific authorization in order to release a patients private health information for treatment, payment and health care operations. Point of Service (POS) Plan ~ is a combination of an HMO and a PPO. Consumer-Driven Health Plan - (CDHP) — combines a high deductible health plan with one or more tax-preferred savings accounts that the patient directs. Health Reimbursement Account ~ (HRA) ~ Medical reimbursement plan set up and funded by ‘an employer. Health Savings Account - (HSA) - designed to pay for qualified medical expenses of individuals who have high deductible health plans and are under the age of 65. 24 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018Flexible Savings Accounts — (FSA) ~ employees can put pre-tax dollars from their salaries in the FSA; then they can use the funds to pay for certain medical expenses. PMPM — Per member per month ‘Schedule of Benefits - medical services covered under the insured’s policy COBRA ‘The Consolidated Omnibus Reconciliation Act (COBRA) gives an employee who is leaving a job the right to continue health benefits under the employer's plan for a limited time. Assignment of Benefits: Reimbursement is sent directly from the payer to the provider. Blue Cross/Blue Shield Plans: Group of independently licensed local companies, usually nonprofit that contracts with a doctor and other health entities to provide services to their insured companies and individuals. Most BC/8S plans offer HMO's PPO’s and POS plans. Co-Payment:_cost- sharing requirement for the insured to pay at time of service. This amount is usually a specific dollar amount. Deductible: A cumulative out of -pocket amount that must be paid annually by the policyholder before benefits will be paid by the insurance company. Eligibility: The qualify factor or factors that must be met before a patient receives benefits. ‘*E.LN: Employer Identification also known as federal tax identification number. Remittance Advice: an electronic or paper-based report of payment sent by the payer to the provider. Encounter Form: also called the superbill:it is a listing of the diagnosis, procedures and charges for a patient's visit. Fiscal Intermediary: An insurance company that bids for a contract with Centers for Medicare and Medicaid Services (CMS) to handle the Medicare program in a specific area. Medical Terminology Word Analysis Healthcare terminology is broken down into word roots, prefixes, suffixes and combining vowels and forms. Word roots, or base words, are the foundation of the healthcare term. A suffix is a word ending, a prefix is a word beginning, and a combining vowel, (usually 0), links the root to the suffix or to another root. The combining form is word root plus the appropriate combining vowel. For example: oste /o/ athr/itis 25 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018Combining Forms and Their Meanings ‘Some combining forms and their meanings: © Arthr/o joint © Bifo life © Blephar/o eyelid © Cardifo heart © Carcinfo cancerous, cancer © Cephal/o head © Cerebr/o cerebrum (largest part of the brain) © Cyt/o cell © Dent/i teeth © Derm/o skin © Electr/o electrical activity © Enter/o intestines © Fet/o fetus * Gastr/o stomach © Hyster/o uterus © Mega/l enlarged © Path/o disease © Rhin/o nose © Sarc/o flesh © Thromb/o clotting * Uo urinary tract Some suffixes and their meanings: ° al pertaining to © -algia pain © asthenia weakness © -dynia pain © -ectomy excision, removal © -emia blood condition © genic produced by, pertaining to producing © globin protein © gravida pregnant woman © itis inflammation © -oma tumor, mass swelling © -osis condition, usually abnormal 26 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018-pathy disease condition state of; condition -sis Some Prefixes and their meanings: Ante- before, in front of Anti~ against Brady- slow Dia- through, complete End, endo within Epi - above, upon Hyper- excessive, above more than normal Hypo - deficient, below, under less than normal Intra within Peri- surrounding, around Pre- before Sub- under, below Suffixes used to describe therapeutic interventions -ectomy excision -graphy process of recording -metry process of measurement “scopy a visualization -stomy ‘anew opening, -tomy incision -tripsy process of crushing Body Structure and Directional Terminology Positional and Directional Terms Anterior (ventral) ~ front surface of the body le of the body Posterior (dorsal) — back Deep - away from the surface Proximal -near the point of attachment to the trunk or near the beginning ofa structure. Distal — far from the point of attachment to the trunk or far from the beginning of a structure. Inferior — below another structure ‘Superior — above another structure ‘Superficial - toward or on the surface Medial — pertaining to the middle or nearer the medial plane of the body 27 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018‘+ Lateral - pertaining to the side ‘* Supine ~ lying on the back Prone lying on the belly © Transverse ~ divides the body into top and bottom halves, Emergency Care All medical administrative assistants should be capable of handling any emergency that presents itself in the office atmosphere. The first step in giving first aid to a patient who appears to be having an emergency (stopped breathing) is to check for a pulse. If it is determined that the patient is having sudden cardiac arrest, use an Automated External Defibrillator (AED). An automated external defibrillator (AED) is a portable device that checks the heart rhythm and can send an electric shack to the heart to try to restore a normal rhythm. AEDs are used to treat sudden cardiac arrest. CPR (Cardiopulmonary resuscitation) may also help in an emergency situation. A crash cart, necessary in cardiac events, would typically be located at the Nurse's station. If an elderly patient collapses in the office, alert the physician immediately. 28 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018Medical Administrative Review Exam 1) Apatient silently rolls up their sleeve to give a blood sample. Which of the following best describes the form of consent the patient provides through this action? A) Expressed consent 8) Silent consent ©) Indirect consent D) Implied Consent 2) Veterans with service related disabilities are eligible for care under which of the following programs: A) VETSERVE 8) CHAMPUS C)—TRICARE Dd) CHAMPVA 3) is usually sponsored and partially paid by an employer. A) Private insurance 8) Worker's Aide C) Group Health Insurance D) —TRICARE 4) The person who owns the insurance is known as each of the following, except: A) Policyholder 8) Dependent ©) Member 0) Subscriber 5) Family members, such as spouse or children that are covered under the member's insurance policy are known as ; A) Members B) Subscribers c) Dependents D) Beneficiaries 6) A physician, specialist or any person that provides medical care is known as the A) Subscriber 8) Provider ©) Policyholder 0) Dependent 29 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 20187) The term refers to the list of charges for each of the provider's services. A) Copayment 8) Fee schedule ©) Coinsurance D) Cost sheet a)A a set amount that the patient may be required to pay the provider before they can receive benefits. A) Copayment 8) Coinsurance ©) Deductible D) Fee schedule 9) Which of the following statements is true under the doctrine of respondeat superior? A) The physician is responsible for any errors made by the medical staff 8) The medical administrative assistant is superior to other members of the medical staff. ©) The medical administrative assistant is responsible for any errors made by the medical staff. D) The person who has been employed for the longest period of time is responsible for any errors made by the medical staff. 10) HIPAA, stands for which of the following? A) Health Insurance Portability and Accountability Act 8) Health Insurance Privacy Assessment and Agreement ) Health insurance Practices and Agreements D) Health Insurance Privacy and Agreements 11) Anna has not received care from any of the health care providers of the same specialty within the previous 3 years. Which type of patient is she? A) Established 8) New ©) Outdated D) —_Re-established 12) The method of scheduling in which one patient is scheduled for a specific appointment time is known as: A) Cluster scheduling 8) Single booking ) Standard scheduling D) Fixed appointment scheduling 30 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018,13) In the event that a group of patients are scheduled to come in to receive the same type of service, the medical assistant should schedule the patients around the same block of time, a method known as A) Multiple scheduling 8) Block scheduling ©) Cluster scheduling D) Frequent booking 14) SOAP is an acronym that stands for: A) Scheduling, objective, assessment and plan. 8) Subjective, opinion, assessment and plan, C) Subjective, objective, assessment and prognosis, D) Subjective, objective, assessment and plan 15). also known as POMR, is a method of tracking the patient's problems during the time they are receiving medical care. A) Prognosis on medical record charting 8) Problem-oriented model records ©) Problems on medical records D) Problem oriented medical record charting 16) A client calls while there is a patient in front of you. What is the best way to handle both people? A) Keep helping the person on the phone B) Ask the person on the phone to hold on and tell the patient you will be right with them ©) Refer the patient to the office manager D) Ask the caller to call back later 17) If there is a window by the reception area, what is the best recommendation? A) Leave it open 8) Keep it closed C) Speak softly to keep patient information private D) Speak through the window 18) In order to find a patient, what is the best way to look up a patient? A) Look up by first name 8) Look up by phone number ©) Look up by social security number D) Look up by last name and date of birth 31 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018it insurance what type of insurance automatically needs 119) When it comes to pati authorization before a procedure can be covered? A) Preferred Provider Organization 8) Health Maintenance Organization €) Point of Service D) Allinsurance 76) What is Preferred Provider Organization insurance? A) _ Isonlya secondary insurance providing deductibles and limits 8) Does not offer discounted rates for provided services ©) Health care providers that have discounted rates for provided services D) Only covers primary care 32 AMCA Medical Administrative Assistant Certification Study Guide (MAAC) 2018