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Chapter 1: The History of Medicine and Health Care The Earliest Medical Practices Early Egyptian Medicine Early Chinese Medicine Early Native American Medicine The Father of Medicine Early European Medicine The Turning Points of Modern Medicine Medical Discoveries The Beginning of Hand Washing in Health Care Antisepsis Use in Health Care The Medical Value of X-rays Chiropractic Practices in Medicine Medicine in the 20th Century Important Organizations in Medical History The History of American Hospitals The History of the American Medical Association The Start of the American Red Cross Important Women in Health Care The Work of Marie Curie The Role of Florence Nightingale The Contributions of the Blackwell Sisters The World Health Organization Medical Care Today Evidence-based Medicine Chapter 2: Medical Assisting Today The History of the Medical Assisting Profession Education Requirements of the Medical Assistant Becoming Accredited in Medical Assisting Achieving Certified Medical Assistant Status Recertifying in Medical Assisting Becoming a Registered Medical Assistant Gaining Multiple Medical Assisting Statuses The Medical Assistant’s Scope of Practice Procedure 2-1: Adapting to Change The Requirements of Other Allied Health Associations The American Medical Technologist (AMT) The American Academy of Professional Coders (AAPC) The American Health Information Management Association (AHIMA) The American Association of Medical Transcriptionists (AAMT) Chapter 3: The Medical Assisting Career: Roles and Responsibilities Choosing Medical Assisting as a Career Understanding Medical Assisting Responsibilities Identifying Positive Medical Assisting Qualities Understanding the Medical Assistant’s Role Outside of the Office Managing Time Effectively in the Medical Office Working in Health Care Today The Medical Assistant’s Career Opportunities Members of the Health Care Team Working with Physicians The Pharmacist’s Role The Role of the Physician’s Assistant The Role of the Nurse Practitioner The Role of the Nurse Medical Practice Specializations Complementary and Alternative Medicine Applying CAM Approaches The Role of Dietary Supplements Chapter 4: Medical Law and Ethics The Sources of Law Administrative Law Comparing Public Law and Private Law Criminal Law Civil Law Tort Law Understanding and Classifying Consent Procedure 4-1: Preparing an Informed Consent for Treatment Form Medical Malpractice The Doctrine of Respondeat Superior Types of Malpractice Insurance Policies Proving Medical Malpractice Medical Malpractice Awards Preventing Medical Malpractice Claims Defending Against Medical Malpractice Claims Using Assumption of Risk as a Defense Contributory and Comparative Negligence Immunity from Negligence Suits Res Judicata and Res Ipsa Locuitur The Standard of Care Tort Reform Capping the Money Awarded to Injured Patients Repeat Offender Providers The Physician’s Public Duties and Consequences Reporting Vaccine Injuries Reporting Cases of Abuse Revoking Medical Licenses The Physician-Patient Relationship The Role of the Patient The Role of the Physician Contracts in Health Care Implied Contracts Expressed Contracts Terminating Contracts The Good Samaritan Act Maintaining Patient Confidentiality through Proper Records Handling Releasing Medical Records Procedure 4-2: Obtaining Authorization for the Release of Medical Records Accommodating Subpoenas of Medical Records Procedure 4-3: Respond to a Request for Copies of a Patient’s Medical Record Disclosing Minor’s Medical Records Guarding Super-Protected Medical Information Faxing Medical Records Disclosing Medical Records Improperly The Health Insurance Portability and Accountability Act (HIPAA) Title II of HIPAA HIPAA and Computer Privacy The HIPAA Privacy Offer HIPAA Records Violation The HIPAA Business Associate Agreement Penalties for HIPAA Violations Advance Directives Employment Law and Health Care Sexual Harassment The Americans with Disabilities Act and Healthcare Employment The Conscience Clause The Patient’s Bill of Rights OSHA and Ambulatory Care The Clinical Laboratory Improvement Amendments Act (CLIA) and Ambulatory Care The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and Ambulatory Care The Controlled Substances Act Medical Ethics Ethical Considerations Ethical Model Raising Ethical Issues in Health Care Bioethics The Uniform Anatomical Gift Act Chapter 5: Interpersonal Communication Skills Verbal Communication Using Non-verbal Communication Writing as a Means of Communication Reading and Using Body Language Therapeutic Touch Demonstrating Active Listening Interviewing the Patient Procedure 5-1: Using Effective Listening Skills in Patient Interviews Employing Interviewing Techniques Identifying Factors that Hinder Communication Communicating in Special Circumstances Procedure 5-2: Communicating with a Hearing-impaired Patient Procedure 5-3: Communicating with Sight-impaired Patients Procedure 5-4: Communicating with Patients via Interpreters Maintaining Professional Patient Communication Communicating with Coworkers Communicating with Other Facilities Procedure 5-5: Preparing a Patient’s Specialist Referral Educating the Patient Working through Miscommunication Taking Time for Patient Education Maslow’s Hierarchy of Needs Establishing a Proper Learning Environment Using Teaching Resources Appreciating the Patient’s Skills and Abilities Factoring Culture into Patient Education Factoring Finances into Patient Education Teaching Patients about Preventive Medicine Preventing Injuries in the Elderly Preventing Medication Errors Providing Dieting or Weight Loss Information Delivering Information on Exercise Educating Patients about Stress Reduction Teaching Patients about Smoking Cessation and Substance Abuse Using the Internet for Education Procedure 5-6: Using the Internet to Find Patient Education Materials Chapter 6: Written Communication Writing to Patients and Other Health Care Professionals The Role of Spell-Checking Reviewing Proper Spelling, Grammar, and Punctuation Use Numbers in Correspondence Rules for Medical-term Plurals The Components of the Business Letter Styles of Business Letters Using Fonts in Typed Communication Procedure 6-1: Composing a Business Letter Sending Letters to Patients Procedure 6-2: Sending a Letter to a Patient about a Missed Appointment Learning How to Proofread Procedure 6-3: Proofreading Written Documents Working with Accepted Abbreviations Creating Memos for the Office Mailing Written Communication Window Envelopes Procedure 6-4: Folding Documents for Window Envelopes Running and Resetting Postage Meters Classifying Mail, Size Requirements, and Postage Buying Postage Online Using Multiline Optional Character Readers “Zip + 4 Codes” USPS-Approved Abbreviations in Addresses Restricted Materials Other Delivery Options Using E-mail to Communicate Managing Mail and Correspondence Procedure 6-5: Opening and Sorting Mail Annotation Procedure 6-6: Annotating Written Correspondence SECTION II: ADMINISTRATIVE RESPONSIBILITIES OF THE MEDICAL ASSISTANT Chapter 7: Telephone Procedures Telephone System Features Making Calls with Hands-free Devices Dialing Numbers Automatically Redialing Last Numbers Called Making Conference Calls Conversing via Speaker Phone Call Forwarding Recording Telephone Calls Direct Telephone Lines Automatic Routing Units Placing Callers on Hold Other Special Features Using an Answering Service Patient Telephone Use Answering the Telephone Procedure 7-1: Answering the Telephone Screening Telephone Calls Directing Patient Calls to Physicians Prioritizing Telephone Calls Telephone Triage Taking Emergency Telephone Calls Being Professional on the Telephone Communicating with Hard-to-Understand Callers Handling Difficult Callers Receiving Calls from Emotional Patients Documenting Calls from Patients Taking Telephone Messages Procedure 7-2: Taking a Telephone Message Calling in Prescriptions and Refill Requests Procedure 7-3: Calling a Pharmacy with Prescription Orders Calling Patients Leaving Messages Calling Other Health Care Facilities Using a Telephone Directory Using an Online Directory Using a Rolodex System Long Distance or Toll Free Calls Guarding Patient Confidentiality Placing Personal Telephone Calls Using Telecommunication Relay Services Chapter 8: Front Desk Reception Characteristics of the Front Desk Receptionist Opening the Office Procedure 8-1: Opening the Office Preparing Patient Files Greeting and Registering Patients Using Sign-in Sheets Effectively Administering Patient Paperwork Notifying Patients of Delays Collecting Payments at the Front Desk Escorting Patients Managing Difficult Patients in the Reception Area Keeping Only Appropriate Patients in the Reception Area Maintaining the Reception Area Providing Adequate Seating and Decoration Choosing Reading Material for the Reception Room Managing Children in the Reception Room Accommodating Patients with Disabilities Serving Patients with Service Animals Caring for Patients as They Leave the Office Closing the Office Procedure 8-2: Closing the Office Chapter 9: Patient Scheduling Scheduling New Patient Appointments New and Established Patients Allowing Appointments Adequate Time Creating an Appointment Matrix Balancing Patient and Office Needs in Scheduling Paper and Electronic Scheduling Procedure 9-1: Scheduling a New Patient Methods of Appointment Scheduling Cluster Scheduling Double Booking Fixed Appointment Scheduling Scheduling with Open Hours Wave Scheduling Leaving Slack or Buffer Time Conducting Triage and Appointment Scheduling Procedure 9-2: Scheduling a Patient Appointment Using Patient Reminder Systems Correcting the Appointment Schedule Documenting No-show Appointments Procedure 9-3: Rescheduling a Missed Patient Appointment Following up on No-Show Appointments Managing the Physician’s Professional Schedule Scheduling Hospital Services and Admissions Procedure 9-4: Scheduling a Hospital Procedure Procedure 9-5: Scheduling an Inpatient Admission Arranging for Language Interpreters Arranging Transportation for Patients Achieving Efficiency in Scheduling Chapter 10: Medical Records Management Information Contained in the Medical Record Procedure 10-1: Preparing the Medical Chart The Purpose of the Medical Record Signing Off On Medical Records Forms of Charting The Narrative Style Charting with SOAP Problem-Oriented Medical Record Charting Inserting Flow Charts in Medical Records Progress Notes Using Abbreviations in Charting Charting Patient Communication Procedure 10-2: Charting Patient Telephone Calls Filing Information via Filing Systems Alphabetic Filing Procedure 10-3: Filing Documents in Patient Medical Records Shingling Items for Medical Records Numeric Filing File Storage Systems Active, Inactive, and Closed Patient Files Converting Paper Records to Electronic Storage Retaining Medical Records Correcting Medical Records Adding to Medical Records Procedure 10-4: Correcting Errors in the Patient Medical Record Charting Conflicting Orders “Owning” the Medical Record Documenting Prescription Refill Requests Releasing Information When a Medical Practice Closes Conducting Research with Medical Records Chapter 11: Electronic Medical Records Electronic Medical Records are Easily Accessible How Does Paper Charting Differ from Electronic Charting? Making the Conversion from Paper to Electronic Medical Records Training Electronic Health Records and HIPAA Compliance Backing up Computers and Electronic Medical Records Using Personal Digital Assistants with Electronic Medical Records Other Benefits of Electronic Medical Records Electronic signatures Using Electronic Records to Avoid Medical Mistakes Saving Time with Electronic Medical Records Using Electronic Medical Records for Health Maintenance Using Electronic Medical Records with Diagnostic Equipment Using Electronic Medical Records for Marketing Purposes Making Corrections in the Electronic Medical Record Chapter 12: Computers in the Medical Office Components of the Computer System Computer Hardware Surge Protection Backing Up Computer Systems Computer Peripherals Scanners Digital Cameras Bar-code Readers Electronic Sign-in Sheets Maintaining Computer Equipment Computer Software Training Staff on Medical Software Types of Software Packages Computer Security Computer Viruses Internet Search Engines Procedure 12-1: Using an Internet Search Engine Finding Appropriate Web Resources Procedure 12-2: Verifying Preferred Provider Status on an Insurance Company Web Site Buying Medications Online Allowing Personal Computer Use in the Office Personal Digital Assistants Computer Ergonomics Chapter 13: Equipment, Maintenance, and Supply Inventory Working with Medical Office Equipment Training Employees to Use Medical Office Equipment Keeping a Maintenance Log for Medical Office Equipment Procedure 13-1: Taking Inventory of Administrative Equipment Procedure 13-2: Perform Routine Maintenance of a Computer Printer Replacing or Buying Medical Office Equipment Weighing Equipment Leasing against Buying Using Fax Machines in the Medical Office Procedure 13-3: Faxing a Document Using Copy Machines in Health Care Work Adding Health Care Data with Machines Medical Transcription Finding Outside Transcription Services Logging Medical Office Supplies Inventorying Supplies Procedure 13-4: Preparing a Purchase Order Checking for the Next Day’s Supplies Storing Supplies Upon Arrival Procedure 13-5: Receiving a Supply Shipment Handling Drug Samples Stocking Clerical Supplies Tracking Supplies with Computer Software Chapter 14: Office Policies and Procedures Creating Patient Information Pamphlets Procedure 14-1: Creating an Office Brochure Creating a Personnel Manual Creating Policies and Procedures for the Medical Office Writing a Mission Statement Preparing an Organizational Chart Mapping Out Clinical Procedures Outlining Administrative Procedures Procedure 14-2: Creating a Procedure for the Procedure Manual Documenting Infection Control Procedures Creating Quality Improvement and Risk Management Procedures Writing Other Office Procedures SECTION III: RESPONDING TO EMERGENCIES IN THE MEDICAL OFFICE Chapter 15: Handling Medical Office Emergencies The Medical Assistant’s Role in an Emergency Preventing Accidents and Injuries Preparing for Medical Emergencies Managing Medical Emergencies Procedure 15-1: Performing Adult Rescue Breathing and Cardiopulmonary Resuscitation Procedure 15-2: Responding to a Patient Who Has Fainted Emergency Equipment and Supplies Administering Oxygen in Emergencies Procedure 15-3: Administering Oxygen to a Patient Automated External Defibrillator (AED) Procedure 15-4: Using an Automated External Defibrillator (AED) The Signs and Symptoms of Heart Attack The Signs and Symptoms of Choking Procedure 15-5: Removing an Airway Obstruction When Infants and Children are Choking Victims Procedure 15-6: Removing an Airway Obstruction in an Infant Controlling Bleeding Procedure 15-7: Controlling Bleeding Assisting Patients in Shock Caring for Patients with Fractures Assisting Patients with Burns SECTION IV: PRACTICE FINANCES AND MANAGEMENT OF THE MEDICAL OFFICE Chapter 16: Insurance Billing and Authorizations The History of Health Insurance Types of Health Insurance Plans Employer-Sponsored Health Plans COBRA Coverage Individual Health Insurance Policies Flex-Spending and Health Care Savings Accounts Fee-for-Service Plans Consumer-Directed Health Care Plans Health Savings Accounts Medical Savings Accounts Flexible Spending Accounts Managed Care Plans Capitation Plans Insurance Coverage Terminology Out-of-Pocked Expenses Waiting Periods and Exclusions Elective Procedures Prescription Drug Coverage Types of Provider Organizations Preferred Provider Organizations Health Maintenance Organizations Exclusive Provider Organizations National Commercial Carriers Medicare Coverage Medicare Part A Medicare Part B Medicare Part C- Advantage Plan Medicare Part D Secondary Insurance with Medicare Medicare for the Employed Providers Participating in Medicare Medicaid Covered Medicaid Services State Children’s Health Insurance (SCHIP) TRICARE CHAMPVA The National Provider Identifier (NPI) Workman’s Compensation Insurance Accidental Injuries Disability Insurance Processing Claims The Patient Identification Number Keeping Patient Information Up-to-Date The Birthday Rule Verifying Eligibility Preparing Referrals, Authorizations, and Precertifications Procedure 16-1: Obtaining a Managed Care Referral Procedure 16-2: Obtaining Authorization from an Insurance Company for a Procedure Documenting Insurance Company Calls Health Insurance Claim Forms The CMS-1500 Claim Form Procedure 16-3: Completing an Insurance Claim Form Accommodating Filing Timelines Billing Insurance Companies Electronically Working within Fee Schedules Posting Payments Reconciling Payments and Rejections Procedure 16-4: Handling a Denied Insurance Claim Sending Supporting Documentation The Office of the Insurance Commissioner Tracing Claims Projecting Health Insurance Costs in the Future Chapter 17: ICD-9-CM Coding The History of Diagnostic Coding Coding with the ICD-9- CM Book The Volumes of ICD-9- CM Volume I ICD-9-CM Appendices Volume II Diagnosis-Related Group (DRG) Coding Determining the Correct Code Primary Diagnoses Coding Conventions Procedure 17-1: Perform Diagnostic Coding Multiple Diagnostic Codes Coding Late Effect Diagnoses Suspected Conditions Signs and Symptoms Codes Coding for Drugs and Chemicals Causing Poisonings or Adverse Effects Coding for Fractures Coding Burns Documenting Diagnostic Codes Chapter 18: Procedural Coding The History of Procedural Coding The CPT-4 Book Categorizing Main Health Care Codes Procedure Codes Evaluation and Management Codes New and Established Patients Selecting the Proper Level of E&M Service Using Coding Modifiers Appropriately Procedure 18-1: Coding for a Procedure Place of Service Codes Anesthesia Codes Postoperative or Follow-up Days Coding for Wound Repair Coding for Same-day Multiple Procedures Radiology Codes Pathology and Laboratory Codes Medicine Codes The Health Care Common Procedure Coding System (HCPCS) Ensuring Proper Reimbursement Fraud in Medical Coding Chapter 19: Billing, Collections, and Credit Identifying Payment Basics Manual Billing Systems Procedure 19-1: Posting and Entry on a Day Sheet Computerized Billing Systems Fee Schedules Participating Provider Agreements Credit and Collections Procedure 19-2: Explaining Professional Fees to a Patient Verifying Patient Identification Managing Accounts Receivables Procedure 19-3: Calling a Patient Regarding an Overdue Account Collection in Managed Care Forgiving Deductibles or Copayments Patients Who File Bankruptcy Professional Courtesy Patient Billing Statements Procedure 19-4: Sending a Patient a Billing Statement Dismissing Patients Due to Nonpayment Charging Interest on Medical Accounts Addressing Checks that Fail to Clear Procedure 19-5: Posting a Non-sufficient Funds Check Contacting Nonpaying Patients Sending Patients Collection Letters Procedure 19-6: Posting an Adjustment to a Patient Account Procedure 19-7: Posting a Collection Agency Payment Uncollectible Accounts Collecting from Estates Overpaying on Accounts Procedure 19-8: Processing a Patient Refund Procedure 19-9: Processing an Insurance Company Overpayment Collections through Small Claims Court Chapter 20: Payroll, Accounts Payable, and Banking Procedures Processing Payroll The History of Payroll Present Day Employment Issues Payroll Processing Creating New Employee Records Updating Employee Records The W-4 Form Recording Employee’s Work Hours Calculating Payroll Computing Payroll Deductions The Circular E Other Deductions Procedure 20-1: Calculating an Employee’s Payroll Using Software to Calculate Payroll Garnishing Wages Accounts Payable Procedure 20-2: Writing Checks to Pay Bills The Checkbook Register Ordering and Receiving Supplies Procedure 20-3: Paying an Office Supply Invoice Preparing a Deposit Slip Procedure 20-4: Completing a Deposit Slip Endorsement Stamps Accessing Bank Accounts via the Internet Petty Cash Procedure 20-5: Accounting for Petty Cash Reconciling Bank Statements Procedure 20-6: Reconcile a Bank Statement Chapter 21: Managing the Medical Office Characteristics of the Medical Office Manager Responsibilities of the Medical Office Manager Leadership Styles Conducting Effective Staff Meetings Creating Staff Meeting Agendas Procedure 21-1: Directing a Staff Meeting Staff Meeting Minutes Staffing the Medical Office Writing Job Descriptions Procedure 21-2: Writing a Job Description Creating Job Advertisements Recruiting and Interviewing Candidates Procedure 21-3: Conducting an Interview Calling for Employee References Procedure 21-4: Calling Employee References Hiring New Staff Training New Staff Supervising Staff Overcoming Scheduling Issues Performance Evaluations Procedure 21-5: Perform an Employee Evaluation Disciplining and Terminating Staff Procedure 21-6: Disciplining an Employee Procedure 21-7: Terminating an Employee Sexual Harassment in the Medical Office Employment Resources Providing Employee References Improving Quality and Managing Risk in the Medical Office Creating a Quality Improvement Program Working to Ensure Patient Safety Reporting Office Incidents Procedure 21-8: Filing a Medical Incident Report Using Protective Equipment Procedure 21-9: Using Personal Protective Equipment Disposing of Hazardous Waste Procedure 21-10: Developing an Exposure Control Plan Ensuring Employee Safety Procedure 21-11: Using Proper Lifting Techniques SECTION V: CAREER STRATEGIES Chapter 22: Competing in the Job Market The Externship Experience Understanding the Extern Site’s Responsibilities Outlining the Student’s Responsibilities The Responsibilities of the Medical Assisting Program Writing an Effective Resume Procedure 22-: Writing an Effective Resume Preparing a Cover Letter Procedure 22-2 Composing a Cover Letter Identifying Places to Look for Employment Completing Employment Applications The Successful Interview Preparing for the Interview Dressing for the Interview Presenting the Right Image Following Up After the Interview Procedure 22-: Following Up After the Interview Changing Jobs Appendix A: CAAHEP Standards for Curriculum: Correlation of Text to CAAHEP Standards Appendix B: Correlation of Text to AAMA Role Delineation Chart Appendix C: Registered Medical Assistant (RMA) [AMT] Medical Assisting Task List Appendix D: Tips on How to Become a Successful Student Appendix E: Preparing for the CMA and RMA Certification Exams Appendix F: Translation of English-Spanish Phrases Appendix G: Common Medical Abbreviations Appendix H: Answers to Chapter Case Studies/Critical Thinking Questions Appendix I: Answers to In-Practice Scenarios Glossary References Table of Contents
Get Administrative Medical Assisting: Foundations and Practices by Christine Malone, Everett Community College
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