Transcript RECORDS MANAGEMENT I

CMAA Review
POWER
POINT #1
CMAA Information for
Allied Health III ( P-Point 1)
IT IS IMPORTANT TO KNOW THE SCOPE OF A CMAA’S
(CERTIFIED MEDICAL ADMINISTRATIVE ASSISTANT)
JOB DUTIES, AND WHAT THEY CAN AND CANNOT DO.
THIS POWER POINT, AND THE 2 FOLLOWING POWER
POINTS, CONTAINS USEFUL INFORMATION THAT WILL
HELP YOU PREPARE FOR THE CMAA INDUSTRY EXAM.
THE ACTUAL CMAA EXAM CONTAINS 110 MULTIPLE
CHOICE QUESTIONS.
T H E E X A M D A T E S W I L L B E A P R I L 3 0 TH F O R S E N I O R S A T
9:00 AM IN ROOM 135 (JUNIOR’S DATE TBA). LAST DAY
T O R E G I S T E R I S A P R I L 2 2 ND
Important
Items in this Power Point that have an *
in front are most likely to be asked on
the CMAA exam in some form. Make
sure you study these well.
This Power Point contains practice
questions 1 - 33. Power point # 2 for
the rest of the information and
practice questions.
Always Keep in Mind……..
 A CMAA, or MAA (Medical Administrative Assistant), is
basically trained to do front office work that includes
secretarial skills. When in doubt about a question about
CMAAs, always think about what a secretary would be
allowed to do at a medical office, and what they would
not be allowed to do.
 On the CMAA Exam, don’t think from the perspective of
a nurse or doctor, or any other health care worker that
we teach about in health science classes. Just think from
the perspective of a front desk person with no medical
training. This can help you narrow down your answers to
the best answer. Remember, MAAs have no medical
training, and you should apply this to your responses.
Medical Specialties
 There may be a few questions on
Medical Specialties, and which organs
& disorders certain specialists work
with on a regular basis.
 For example: If you were told you had
an MI, or Myocardial Infarction (heart
attack), the specialist you would see
would be a Cardiologist.
*Specialists to Know about and what kind of
referrals they get.
 *Cardiologist (heart specialist) – MI, Angina, CHF
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(congestive heart failure), Hypertension, EKG
interpretations, etc.
*Pulmonologist (lung specialist) – COPD, asthma,
emphysema, lung cancer, etc.
Gastroenterologist (stomach & intestines) – colon
cancer, ulcers, digestive system disorders
Neurologist (Nervous system) – EEG interpretation,
brain tumors, spinal injuries, head injuries, seizures
*Nephrologist ( renal functions & kidneys) – dialysis
and renal failure, etc.
Specialists Question (1 of 150)
• A patient calls with history of an MI and CHF, and
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needs to be referred to a specialist. Which specialist
would the Medical Assistant contact?
A. neurologist
B. cardiologist
C. urologist
D. pulmonologist
Answer
B. Cardiologist (MI is a myocardial infarction and CHF
is congestive heart failure)
Specialists Question (2 of 150)
*A patient calls a multi-specialty practice to schedule a
consult to discuss the results of a renal function
panel. With which of the following providers should
the patient be scheduled?
A. Hematologist
B. Gynocologist
C. Nephrologist
D. Endocrinologist
Answer: C (Nephrologists deal with kidneys, or renal
functions)
FILING
 *Alphabetical Filing:
 Folders
are arranged in the same sequence
of the alphabet
 The
Medical Assistant must ensure that the
filing cabinet has enough space for proper
distribution of the files amongst each letter
of the alphabet.
RECORDS MANAGEMENT
FILING
 Numerical Filing:
 An alphabetic cross-reference is used to categorize materials
with digits
 Patients are assigned in a consecutive number
 Records are filed backwards in groups
 Example: Terminal digit filing
FILING.
On the CMAA exam, you may have to place a list of
names in order, or state “which comes 2nd, 3rd etc.”
The Medical Administrative should use the following indexing
rules for alpha. order:
 Last Name, First Name, Middle Name/Initial
 Always remember, “nothing comes before something”, such as
Brown, Mark is filed before Brown, Mark A.
 The hyphenated portion of a name is used as one unit;
Example: Anna Smith-Meyer is filed Smithmeyer, Anna
 Apostrophes are not used in filing
 Titles, and terms of seniority, are only used to distinguish
from an identical name
 When indexing a company, articles such as “The” and “A” are
not used
 Example: The Mandarin Office is filed as: Mandarin Office
Filing Question (3 0f 150)
*A provider has an alphabetic filing system. Which of
the following patients should be filed second?
 A. Eddie Thomas
 B. Elyse St. Thomas
 C. Mandy Thomas-Morgan
 D. Susie Lee Morgan-Thomas
Filing Question
Answer: B
Filing Question (4 of 150)
Which name should be filed last alphabetically?
A. Steve McNair
B. S. S. McNair
C. Steve S. McNair
D. Steve M. McNair
Answer to Filing question
 Answer: C (Steve S. McNair)
Filing Question (5 of 150)
Which should be filed first numerically?
A. 007
B. 7
C. 77
D. 70
Answer to Filing question
Answer: B (7)
RECORDS MANAGEMENT
FILING
*Tickler File
 A collection of date labeled folders used as a
reminder for time-sensitive matters or other
important information
 It’s used as a follow up method for appointments
(it “tickles” you to remind you)
 Should be checked each day
*Tickler File Question ( 6 of 150)
* Which of the following is the first step a medical
administrative assistant should complete when
creating a tickler system to mail reminder letters?
 A. Check future appointments
 B. check patients account balances
 C. Verify patients insurance information
 D. Very names and addresses of patients
Tickler File Answer
Answer: A
(A CMAA should check future
appointments before creating a
tickler file)
Mail-related Medical Terms/Vocabulary Terms
refresher
 Express Mail-the type of mail available every day of the
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year, including holidays, for items up to 70 lbs
(pounds) in weight and 108 inches in height.
First-class mail- this includes letters, post cards, postal
cards, and business reply mail.
Priority Mail- First-class mail that weighs more than 13
ounces
Certified Mail-this type of mail gives the sender the
option to receive proof of delivery.
Bulk Mail- – a form of mailing large volumes of
information which is presorted by zip code
*Mail Question 1 (7 of 150)
 *A provider needs to mail two medical books
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weighing a total of 14 lbs to an office across the
country. He wants the books to arrive in 1 week.
Which of the following is the most economical
delivery service to use?
A. Express Mail
B. Media mail
C. Bulk mail
D. Priority mail
Answer to mail question 1
Answer: D (Priority Mail)
Mail Question 2 (8 of 150)
*A Medical Assistant wants to mail out 10 business
letters to local doctors in the community. Which
type of mail should be used?
A. Priority mail
B. Express mail
C. Bulk mail
D. First-class mail
Answer to mail question 2
Answer: D (First-class mail)
Medical Terms/Vocabulary Terms review
*Abandonment – the discontinuation of medical
care without proper notice to the patient.
 Arbitration – the usage of an impartial third party
for the hearing and determination of a dispute.
*Good Samaritan Act – states that a
volunteer/CMAA is not held liable for any civil
damages that may occur as a result of a health care
worker’s efforts to provide first aid or any type of
emergency care. This law protects physicians
(doctors) and other health care workers from being
sued.
Question (9 of 150)
 *If a provider goes out of town without ensuring
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coverage during her absence, a patient could initiate
a lawsuit on the grounds of
A. abuse
B. negligence
C. malpractice
D. abandonment
Answer:
D (Abandonment)
Legal Terms review
*Battery – the unlawful use of force or violence, or
operating on someone without their consent.
 Assault – the threat of using force or violence.
*Negligence – failure to provide the necessary care
that is required.
 Malpractice – professional negligence; where a
doctor does not perform up to standards.
*Statutes – laws enacted by the legislative branch of
government.
Patient’s Rights
*Patients’ Rights – a document developed to
ensure the fairness and effectiveness of the health
care system. It protects the patient and the
employer. A patient has a right to confidential
treatment of their medical records, and privacy
concerning a medical care program.
Confidentiality – information about a patient
must remain private and must be shared only with
other members of a patient’s health care team.
(10 of 150)
*When releasing confidential information, who has the
right to decide how and to whom the information is
communicated?
A. The patient
B. The provider
C. The office manager
D. Medical administrative assistant
Answer
A (the patient decides who
information can be shared
with)
(11 of 150)
* A provider did not obtain an informed consent from
a coherent patient before surgery. The provider can
be charged with which of the following
A. Assault
B. Libel
C. Battery
D. Negligence
Answer
C (Battery. This is the type that does not involve the
traditional “hitting” or touching a patient associated
with violence)
(12 of 150)
 The mother of a child with flu like symptoms is checking
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into the doctor's office. Which of the following is the
proper protocol to help prevent the spread of illness?
A. Have the mother cover the child's mouth with her
hand
B. Demonstrate proper hand washing technique to the
mother
C. lead the mother and child to a designated reception
area
D. Direct the mother to clean the children's toys with
1:10 bleach and water solution
Answer
C (lead them to another reception area that is away
from others)
Health Insurance terms to review. You may have to do a few
math questions related to deductibles and co-pays.
 Assignment of Benefits – authorization by an insured
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patient to an insurer to pay a claim directly to a third
party (such as a doctor).
Benefit – money paid by ins. Co.
Deductible (see next slide)
Copayment – small fee paid at time services are rendered
by a provider; also called a copay.
Policy – document detailing conditions of insurance
Premium – payment made to ins. Co.; costs
Waiting Period Claim – a bill submitted to an ins. Co.
Deductibles and Co-payments (co-pays) review
 Your deductible is the amount of money you must
pay for health care services before your insurance
company will begin paying your medical costs. It is
usually a set amount between $250 and $1,000 and
it resets every year.
 Once you have paid off your deductible within a
given year, you may only have to pay a co-payment
to your doctor for a visit. This is a set amount that is
due at the time of your service (doctor visit), and is
usually around $20 - $25.
review
 Allowable (allowed) charges – discounted fees
that insurance companies negotiate with doctors or
other providers. It’s the maximum amount an
insurance company will reimburse a provider for
their services.
(13 of 150)
 Which of the following should the MAA verify when
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filing documents in a medical record?
A. Date of birth
B. billing address
C. Insurance provider
D. Referring physician
Answer
C (Insurance provider)
Question ( 14 of 150)
 * A new patient calls the providers office and
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inquires about general billing policies. Which of the
following is an appropriate response?
A. Payment is due on the day of visit
B. Your copay amount will be applied to your
balance
C. you will need to contact your insurance company
about all financial inquiries
D. We can address your question once your
insurance coverage has been verified
Answer
D. We can address your question once your
insurance coverage has been verified
(15 of 150)
*The total charge for today's office visit is $172, of
which $146 is allowable. The patients co-payment is
$20, and the $300 deductible has been met. Which
of the following amounts does the patient owe for
today?
A. $20
B. $26
C. $128
D. $168
Answer
A. ($20)
(16 of 150)
A patient has $50 left to meet her deductible and a
20% coinsurance. The total charge for todays
services is $200. The third party payer allows $150.
Which of the following amounts is the patient’s
responsibility for today visit?
A. $50
B. $70
C. $80
D. $150
Answer
C. ($80)
Medical Record Management review
 Creating a Medical Record- The Medical
Administrative Assistant should take the following
steps to establish a patients medical record:
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Determine the patient’s Status in the office (New or
Established)
Obtain the required general information
Enter the information into the patients history form
Review the form accuracy
Enter the patient’s name into the computerized ledger
Assemble the forms, prepare the folder and file as necessary
(17 of 150)
 Which of the following is part of the check out
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process in a providers office?
A. Asking for a valid ID
B. Obtaining proof of insurance
C. Reviewing the patients diagnosis
D. Collecting payment from the patient
Answer
D (collect the payment during check-out. *Often the
co-pay is paid at the beginning as the patient arrives)
CMAA REVIEW
What does the Acronym SOAP
mean?
Component of patients medical record:
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*SOAP APPROACH – This is a
format for progress notes based on the
letters of the word SOAP.
 S = Subjective Impressions
 O = Objective clinical evidence
 A = Assessment or Diagnosis
 P = Plans for further studies, treatment, or
management
Question on SOAP (18 of 150)
*A provider (physician) sees a NP (new patient) and
makes a diagnosis of anemia. Where in the progress
notes would this be verified?
A. Subjective
B. Objective
C. Assessment
D. Plan
Answer
 C (Assessment; the A represents an assessment or
diagnosis)
Question on SOAP (19 of 150)
*A physician diagnoses a patient with a fracture and
recommends physical therapy three times a week for
45 min, for 4 weeks. Where in the medical record can
the MAA verify this information?
A. Subjective
B. Objective
C. Assessment
D. Plan
Answer
D (Plan)
(20 of 150)
 *A patients calls the physician's office and insists on
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viewing his medical record after receiving an
incorrect explanation of benefits(EOB). Which of the
following actions should the MAA take?
A. Schedule an appointment with the office manager
B. Schedule an appointment with the physician
C. Mail the patient his medical record
D. Mail the patient a corrected EOB
Answer
A (schedule an appointment with
the office manager to discuss the
matter)
Medical Record Management review
Component of patients medical
record:
 Personal and Medical History (Hx) – Created
using information gathered from the patient. Usually
includes information such as past illnesses, surgical
operations, and the patient’s daily health habits.
 *Patient’s Family History – this information is just
as important as the patient’s personal and medical
history. Includes information regarding the health of
members of the patient’s family, and a record of the
causes of death. Remember, the medical records of a
spouse is not important because they are not “blood
relatives.”
Medical Record Management
Component of patients medical
record:
 Patient’s Social History – Includes information
regarding the patient’s lifestyle. Examples include
smoking and drinking habits.
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 Diagnosis (Dx)– a decision made based on the
information regarding the patient’s history and the
results of the doctor’s examination.
Basic Telephone Techniques review
 Since the Medical Administrative Assistant is
responsible for answering telephone calls, it is
imperative to have solid communication skills.
Question
 Have you ever called a doctors office, or spoken with
a receptionist who was rude and short with you on
the phone? How did it make you feel?
Basic Telephone Technique(Etiquette)
 The following steps will ensure proper telephone
etiquette
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Answer the telephone promptly and kindly.
Be sure to properly speak into the phone
Be sure to give the caller your undivided attention
Speak clearly and distinctly.
Always be courteous
Be sure to ask the caller’s permission before placing them on
hold
Never allow an angry or aggressive caller to upset you; remain
calm and composed
Always allow the caller to hang up first.
Basic Telephone Technique(Etiquette)
 Verbal and Non-Verbal Communication
 Verbal communication is the use of the language or the
actual words spoken. Some of the key components of verbal
communication are sounds words, speaking and language.
Non-Verbal Communication is use of eye contact, body
language, facial expression, or symbolic expressions to
communicate a message
Questions:
1. Is Texting a form of verbal or non-verbal communication?
2. How can you recognize positive non-verbal communication
verses negative non-verbal communication?
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Basic Phone (Etiquette)
 Respect
 Respect is essential in the process of communication
with co-workers, patients, and visitors. The following
steps will help to create a comfortable environment:
Refrain from making jokes or negative remarks that demean the
abilities, skills, or aspects of co-workers
 Be patient and respectful when speaking with a caller that does not
speak English clearly
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THE MEDICAL ASSISTANT’S ROLE
 Personal Qualities that the Medical Assistant should
possess are: Dependability, Courtesy, Initiative, and
Interpersonal Skills.
 Duties of the MAA include: Telephone coverage,
scheduling, maintenance of medical records, and the
management of all correspondences (communicating
by exchange of letters).
 They may serve on committees, but may not make
any final decisions or sign off on any official letters
or documents.
Important
 If you are a CMAA (MAA) and you are on the phone
with a patient who is complaining of chest pain or
something potentially serious, tell them to call 911
immediately! Even though you may be working in
a doctor’s office, this could be a medical emergency
that your office is not designed to handle. For any
medical emergency, patients should always call 911.
The CMAA’s role Question (21 of 150)
*Which of the following is out of a MAA's regular job
function (something they can’t do)?
A. Approving minutes and signing letters
B. Typing memos letters and reports
C. Updating encounter forms and medical records
D. Maintaining invoices, forms and financial
statements
Answer
A ( A CMAA cannot sign off on letters or
medical records)
Medical Terms/Vocabulary Terms review
 Hard Copy – Computer term for a printed copy of
information
 Inside Address –That section of a letter that contains
the name and address of the person or firm to whom the
letter is being sent. Example on page 858
 *Wave scheduling – A certain number of patients are
scheduled to arrive at the same time and patients are
seen in order in which they arrive.
 *Modified Wave scheduling – Small groups of
patients are scheduled at intervals throughout the hour.
Scheduling question (22 of 150)
 *Which of the following is most likely to result in
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adequate patient flow
A. Rescheduled appointments
B. Emergency appointments
C. Wave schedule
D. Double booking
 Answer: C (Wave Schedule)
(23 of 150)
 Which of the following is the first step in helping a
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patient remember a follow-up appointment?
A. Call the patient as a reminder
B. Mail the patient a reminder card
C. Hand the patient a reminder card
D. Have the patient confirm the appointment
Answer
C (Handing a patient an
appointment card is the first
thing you should do after
making a follow-up
appointment)
(24 of 150)
 *During a call with a patient who is scheduled for a
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provider visit, the MAA should end the conversation
with which of the following?
A. Insurance verification
B. The patients address
C. Social Security number
D. Appointment confirmation
Answer
D (Appointment verification)
Question (25 of 150)
*A patient calls and cancels an appointment with less
than 24 hr notice. Which of the following actions
should the MAA take?
A. Call other patients who have not been seen recently
if they would like to make an appointment
B. Extend the time allowed for other appointments so
that the providers time is evenly distributed
C. Call patients scheduled for later in the day and ask
if they would like to be seen earlier
D. Place the patient on hold and follow up with the
office manager
Answer
C. Call patients scheduled for later in the day and ask
if they would like to be seen earlier
Medical Terms/Vocabulary Terms
 Double booking – Scheduling two patients to see
the doctor at the same time.
 NP = new patient
 *Block Letter Style- Letter format in which all
parts of the letter start at the left margin
 *Modified Block letter style - Letter-writing
format in which all parts of the letter start at the left
margin except the heading, complimentary closing,
signature, and title, which starts at the center.
Examples in Simmers book.
Addressing a letter properly (26 of 150)
 Which of the following is appropriate when
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addressing a business letter?
A. Dear Doctor Jones
B. Dear Dr. Jones, MD
C. Dear Robert Jones, MD
D. Dear Doctor Robert Jones
E. None of the above
Answer on next slide
Answer
 Answer: A (Dear Doctor Jones; or Dear Dr. Jones
would be acceptable as well)
(27 of 150)
*Which of the following is a characteristic of a blockstyle letter?
A. Salutation is flush left
B. Body of letter is double spaced
C. Typed signature begins in the center
D. First line of paragraph is indent five spaces
 A. Salutation is flush left
The CMAA’s role and limitations (28 of 150)
*Which of the following is an example of an appropriate
interaction between a patient and a medical
administrative assistant in the reception area?
A. Offer to educate a family member of the patient about a
diagnosis or procedure
B. Be supportive and share a similar experience with the
patient
C. After the appointment, explain directions to the patient
for any prescribed medications
D. After the patient has signed in remove the patients
name from view on sign-in sheet
Answer
 Answer: D (this is the only option; the other options
would be acceptable for medical professionals only)
Question (29 of 150)
*After the MAA composes a business letter, under
which of the following circumstances must the
physician sign the letter?
A. Letters to colleagues or offices of a medical society
B. Notifications to patients
C. Letters of solicitation
D. Letters arranging or rescheduling appointments for
patients
 A. Letters to colleagues or offices of a medical
society
CEUs
Continuing Education for the CMAA:
Like most professions, the medical assistant must stay
current by taking special courses throughout the year.
This will allow a CMAA to stay certified without having to
take the certification exam over and over again every two
years.
CEUs, or Continuing Education Units, are the best way to
stay current. These units are obtained throughout the
year by attending special workshops or trainings. Each
workshop will give you a certain number of CEUS, and
you will need to accumulate a set amount every couple of
years to maintain your certification.
Question ( 30 of 150)
 Which of the following must MAA's do in order to
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keep their certification current?
A. Attend staff meetings
B. Submit CEU's
C. Publish an article
D. Retest annually
Answer
B (Submit CEUs. This is a better alternative rather
than retesting)
New Patient question (31 of 150)
*A new patient is inquiring about office policies and procedures.
Which of the following is an appropriate response from the
medical administrative assistant?
A. "Here is a copy of our policies and procedures"
B. "The nurse will provide you with policies and procedures in the
exam room"
C. "I will provide you with a detailed list of policies and procedures
after your visit today"
D. Per HIPAA regulations, you must sign a release before receiving
our policies and procedures"
See next slide for answer
Answer
 Answer: A (The CMAA can give a copy of the policies
and procedures to a patient as requested by the
patient. They may not discuss any medical concerns
or answer any medically-related questions with
patient.)
(32 of 150)
*Where should completed medical record request be
kept?
A. In the patients chart
B. In a separate marked file
C. In the tickler file
D. With the insurance company
Answer
A (in the patient’s chart)
(33 of 150)
*A MAA calls a 17 year old patient by only her last
name in the reception area to provide additional
contact information. Which of the following is the
reason the assistant calls for the patient in this way?
 A. The patient is a minor
 B. It prevents disclosure
 C. It is improper to call a patient by her first name
 D. It is a HIPAA violation to address the patient by
her first name
Answer
 B. It prevents disclosure of personal information.
The least amount of information should always be
disclosed, or said aloud, when others are around.