The World of Health Care - Weston Distance Learning

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The World of Health Care

LESSON1

Step 1 Learning Objectives for Lesson 1

When you have completed the instruction in this lesson, you will be trained to do the following:

Explain an average day in a medical office.

List the different types of medical personnel and explain how each role helps to ensure quality health care.

Describe your role as a medical coding specialist.

Discuss the job opportunities available in your new career.

Identify several types of medical records found in the healthcare world.

Step 2 Lesson Preview

Chances are that you’ve been to the doctor’s office and maybe even your local hospital a few times in your life (though hopefully not too often!). You’ve seen doctors, nurses and office administrators hard at work in these settings, but how much do you really know about what they do? Well, in this first lesson, we’ll introduce you to the activities that go on in doctors’ offices.

You’ll also see where you, the medical coding specialist, fit in! You’ll learn about your future job duties and see how you will interact with other healthcare professionals. We’ll also discuss a few of your many job opportunities. Lastly, you’ll get a look at the medical records that coding specialists handle on a daily basis. The physician’s opinion about what is

wrong with the patient or what is causing the patient’s complaint is the diagnosis.

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Medical Coding Specialist

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Did you know that medical coding specialists are in demand throughout the country because of the vast numbers of doctors and patients? More doctors are needed now more than ever to take care of our aging population. This is where you, the medical coder, come into play. According to the U.S. Bureau of Labor Statistics, medical coding is one of the ten fastest-growing allied health occupations. Doctors need coding specialists and are willing to pay well for the services they provide. Well-trained medical coders make a lot of money. Medical coders often make $35,000 per year or more. And in time, with practice, patience and hard work, you could earn more than $50,000 per year!

You are off to a terrific start by choosing this course as your education for your exciting new career. In fact, the American Academy of Professional Coders (AAPC), the renowned coding association, recognizes the comprehensive quality of this course. This means the AAPC allows graduates of this recommended program to waive one of the two years of coding experience needed to become a Certified Professional Coder.

As you go through this program, you can feel confident that you are learning from the experts. The school has been providing quality home-study education for over 30 years. We pride ourselves on our students’ accomplishments! People just like you are working in exciting jobs today because of the investment they made in their education—we are here when you need us. If you have a question, just pick up the phone and call. It’s that easy. Now let’s take those first steps on the path to your new career.

Step3 DailyActivitiesintheMedicalOffice

To fully understand what a medical coding specialist does, you first must understand how medical office personnel gather information. This information includes patient data; insurance company information; and doctors’ procedures, diagnoses and other actions.

To illustrate all of this, let’s take a look at a typical day in a medical office, or an outpatient setting. (Outpatient settings include clinics, physicians’ offices, outpatient surgery facilities and hospital emergency departments. Inpatient settings include hospitals—or facilities where patients are admitted for an overnight stay.) We’ll get the point of view of the first person to see patients—the office manager or receptionist—and then we’ll look at the doctor’s perspective.

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A Day in the Life of the Medical Office Manager

Hannah is the office manager for Mercy Medical Center, a busy, family medical clinic that has three doctors. As the first person to see patients, she tracks them as they arrive and check in for their appointments. Today, each doctor is scheduled to see about 15 patients. Hannah’s appointment book contains a different page for each doctor’s schedule. Her day begins with the 8 a.m. appointments. Each doctor has a bright-and-early patient scheduled. By 7:55 a.m., two of the three patients are in the waiting room. One is a new patient at the clinic, and she is filling out the “New Patient Questionnaire.” The other is an established patient.

Hannah pulls out the medical files for the established patient. The medical files are thick, manila folders and are coded on the tab according to the patient’s last name. She prints an encounter form or super bill for the established patient and uses a paperclip to attach it to his folder. She then places the files in the “Patients to See” stack for the nurse of one of the doctors.

The new patient brings up her completed questionnaire, and Hannah spends the next few minutes creating medical files for this new patient. Hannah makes a new folder for the patient, labels it appropriately and places a copy of the questionnaire in it. Then she takes the original questionnaire and types the information from it into her computer. This creates two files for the patient—one in the computer and one on paper. After Hannah has entered the information about the patient into the computer, she prints an encounter form or super bill. She then clips the encounter form to the appropriate folder and places it in the “Patients to See” stack for the appropriate nurse.

It is now 8 a.m., and one appointment has yet to arrive. At 8:04 a.m., Hannah receives a call from the missing patient. He is having car trouble and can’t make it today. Hannah assures the man he can reschedule. She sets up a new appointment for him and logs it into the doctor’s appointment book. By 8:06 a.m., both of the other appointments are back in the examination rooms. The 8:15 a.m. appointments begin to arrive. The routine is similar to the first group of patients except that this time all three appointments arrive. They all are established patients, so Hannah pulls their files, prints out encounter forms and distributes the folders to the correct nurses.

At 8:10 a.m. the first doctor is finished with his 8 a.m. appointment—a man named Jim Burgess. Mr. Burgess walks out of the examination room and gives the encounter form or super bill to Hannah. Hannah looks at the procedures that the doctor circled and quickly fills in an amount next to each one.

Medical office managers handle multiple tasks.

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She totals the bill—$187.50—and has Mr. Burgess sign it. At Mercy Medical Center, most patients are covered by insurance. In Mr. Burgess’s case the medical office will send the bill to the insurance company without him paying an initial copayment or the entire amount of the bill. Therefore, Mr. Burgess signs the bill to give the insurance company permission to pay the clinic directly and returns it to Hannah. She rips off the back copy for him.

As Mr. Burgess picks out a lollipop from the basket on the counter, Hannah quickly files the completed and signed encounter form in her “To Submit, Current” folder. The nurse has returned Mr. Burgess’s file, so Hannah puts it in the “To Be Updated” basket. The folders in this basket are waiting for the doctors’ dictation to be transcribed. Just then the telephone rings. It is Mercy Medical Center’s medical transcriptionist calling to verify a patient’s information. Hannah explains she will have to look up that information and call the transcriptionist back.

Hannah’s day continues this way until she leaves at 5 p.m. During that time, she continually checks in patients, enters new questionnaires on the computer, creates files, retrieves files, completes encounter forms, answers the telephone, and schedules and reschedules appointments.

Now let’s look at the same day’s events from a physician’s perspective.

The Doctor’s Point of View

Dr. Green is one of the physicians for whom Hannah works. He sees his first patient at 8 a.m. He examines the patient, a woman

in her mid-30s, and determines the cause of her ailment. Dr. Green’s patient has a broken arm. When she sees Dr. Green, he listens while she tells him what’s wrong—this is called the chief complaint. Then Dr. Green looks at her arm and recommends that x-rays be taken. Finally, since the x-rays show a fracture, Dr. Green puts her arm in a cast.

This sequence began with a chief complaint—“my arm hurts”—and was followed by a diagnosis aided by tests—a

broken arm as seen on the x-ray. The sequence is completed with a treatment or procedure—the fracture care. Doctors

perform one or more of these steps with every patient they see.

And every time a doctor or nurse performs these duties, the steps must be recorded into the patient’s history, which is a folder usually called a chart. The diagnosis and treatment or procedure, along with any tests done, eventually are coded by you, the medical coding specialist! You will learn all about coding diagnoses, tests and treatments as you move through this course. For now, you just need to understand where you will gather that information.

Doctors perform many steps when they see patients.

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After Dr. Green examines the patient, he records some notes about the encounter. The office’s medical transcriptionist will use this dictation to transcribe the encounter into a formatted medical report. Dr. Green also makes some notes on the patient’s history or chart. Now, he is ready to see his second patient.

You have a basic idea of the everyday activities in a healthcare facility, so let’s review what you’ve learned so far.

Step 4 Practice Exercise 1-1

Choose the best term to complete each sentence. Not all terms will be used. None of the terms will be used more than once.

nurse billing form complaint office manager super bill exam diagnosis codes problem transcribes

1. The ___________________________________________ is usually the first person in the doctor’s office to see a patient.

2. The encounter form also is called the __________________________ ________________________________________________.

3. When the patient tells the doctor what’s wrong, this information is called the chief _______________________________.

4. When a doctor sees a patient, the three steps in the sequence include the complaint, __________________________________________, and treatment or procedure.

5. The medical coding specialist ___________________________________ the diagnosis and procedure.

Step 5 Review Practice Exercise 1-1

Check your answers with the Answer Key at the back of this book. Correct any mistakes you may have made.

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Step 6 A Little Teamwork Goes a Long Way

Now you know how information flows in medical settings. You have a basic understanding as to what some healthcare employees, such as office managers and doctors, do in a typical day in a medical office. But before we talk about your role in the healthcare team, let’s identify some of the key players in hospitals and doctors’ offices and elaborate on what they do.

In most professions, teams of people work together to accomplish goals, and this is true of physicians as well. In medicine, doctors certainly cannot perform their jobs alone. Many people work hard, some behind the scenes, others more visibly, to ensure that the healthcare system runs properly. When you go to see the doctor, you don’t just see the doctor. You might see a number of professionals, including a receptionist, an office manager and a nurse. Throughout a visit, a doctor may talk to several staff people, including the medical coding specialist. All of these people are essential members of the medical care team.

Success comes from a team of people working together to accomplish goals.

Physicians

Physicians or doctors are the most prominent members of the medical care team. They perform life-saving procedures. They cure the sick and help heal wounds. Becoming a doctor of medicine is one of the most challenging career paths a person can choose. Not only do doctors earn four-year college degrees, but they also must complete medical school and one or more residency assignments. During residency, 85- to 100-hour work weeks are common. Because of this huge commitment, doctors deservedly receive much of the attention in the medical field.

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Physicians diagnose illnesses and injuries. They prescribe drugs to alleviate symptoms, treat conditions and ease pain. They rely on their training to make quality, accurate decisions. However, as good as physicians are, their staff ultimately supports them as they provide quality treatment. Nurses are one essential part of the medical staff.

Nurses

As professionals who perform a variety of tasks in the medical world, nurses often must follow through with treatments physicians prescribe. Nurses can give injections and check a patient’s vital signs, as well as assist in surgery. It’s also true that nurses must often do the thankless jobs—cleaning up exam rooms and organizing supplies.

Without nurses, the number of patients a doctor sees in a day would drop dramatically. Because of their nurses, doctors see more patients and are able to focus on those patients who require the most care.

Nurse’s and Physician Assistants

Two other categories of personnel in the medical field are nurse’s and physician assistants. Nurse’s assistants, or nursing aides, help nurses with daily duties, such as paperwork, general organization and taking a patient’s temperature, weight and blood pressure. Some nurse assistants also talk to patients and make sure they’re comfortable.

Physician assistants or PAs normally are under the supervision of a doctor, and can perform some of the same functions as a doctor. PA duties might include stitching up a cut, taking a patient history and even performing lab work.

Support Staff

Doctors and nurses rely heavily on support staff to keep a medical office or clinic running smoothly. As you might guess, each of these positions plays an important role in the medical world.

Medical Billing Specialists

Medical billing specialists are a perfect example of how interrelated one job is to the next in a medical office. Remember, coding specialists code what occurs during a patient’s medical visit, while medical billing specialists use the codes that a medical coder assigns. Billing specialists then complete the insurance forms necessary to collect payment from the insurance companies. These specialists know that the doctor doesn’t get paid unless the form is completed and filed correctly. Billing specialists have training in medical terminology, medical records handling and some basic coding.

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Medical Transcriptionists

Do you remember when the doctor in our previous example recorded some notes about a patient encounter? Well, that dictation went to a medical transcriptionist who listened to the doctor’s dictation and typed what she heard. This then was added to the patient’s medical record. By using transcriptionists, doctors save time by speaking their notes.

Medical transcriptionists type the doctor’s dictation.

While you don’t need to know every aspect of medical transcription, you should be aware as to what transcribed reports look like. As a medical coder, you often will work from these transcribed reports. Two examples of transcribed reports follow: one for Laura Brown and one for Johnny Cruz. Study these reports so that you have a better understanding of a transcriptionist’s role in the medical records process.

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Transcribed Report Example OneName: Laura Brown#030311

PROBLEMUpset stomach with vomiting and fever.

SUBJECTIVEThe patient is a 22-year-old female. She went to breakfast with her friends earlier this morning. She ordered a cream-filled pastry with her coffee. She stated that no one else had a pastry. About 4 hours later, she started having an abrupt onset of nausea, vomiting, abdominal cramps, diarrhea, headache and a slightly elevated fever. Since she had the symptoms for over three hours, she called her family physician and was able to see him this afternoon.

OBJECTIVEPhysical examination reveals a well-developed, well-nourished female in acute distress. Blood pressure: 125/85. Temperature: 99.6°F. Pulse: 88. Respirations: 24. Chest is clear. Cardiovascular examination: Regular rate and rhythm. Abdomen: Positive bowel sounds. Diffuse tenderness with slight pain. Laboratory results indicated a slightly elevated white blood cell count. Abdominal x-ray: Normal.

ASSESSMENTStaphylococcus toxin gastroenteritis.

PLANThe patient was sent home and told to get plenty of bed rest and begin clear fluids when nausea and vomiting cease. If the symptoms continue for more than 3 more hours, she should contact the office.

_______________________________________Robert Snow, MD

D:02-08-20xxT:02-08-20xxRS:CJL

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Transcribed Report Example TwoName: Johnny Cruz#030315

PROBLEMSore throat with fever.

SUBJECTIVEJohnny, a 5 year old, presents to his pediatrician with a sore throat, fever, loss of appetite and a headache. His mother said that he has been on the couch all morning and refuses to eat or play.

OBJECTIVEAfter examining the patient, the doctor reports enlargement of the lymphatic glands and a temperature of 103°F. The oral exam reveals a swollen, bright-red throat. A throat culture is postitive for strep throat.

ASSESSMENTAcute follicular pharyngitis.

PLANTake erythromycin as directed. Temperature to be taken frequently. Children’s Tylenol every 4-6 hours as needed for fever. Encourage bed rest, modify activities and increase fluid intake. All citrus juices should be avoided until symptoms subside. Call office if symptoms persist.

________________________________________Marikit Makabuhay, MD

D:09-15-20xxT:09-15-20xxMM:BDD

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Medical Record Technologists

Certified medical record technologists control the flow of medical records to the various people who need to see those records. These technologists take a certification test that ensures they have the knowledge to determine what records are needed, who is authorized to see the records, and how these records are organized. You may find that medical record technologists, who are certified, are also called Registered Health Information Technicians or RHITs.

Emergency Personnel

Emergency personnel are a group of professionals with the sole responsibility of providing immediate medical assistance and transporting the patient to the hospital for treatment. When someone is hurt and needs an ambulance, these people respond. Police officers, firefighters and other rescue professionals all have some level of medical training.

You probably have heard of emergency medical technicians (EMTs) and paramedics. EMTs take classes that enable them to stabilize patients who have a wide variety of emergency medical conditions. They often are members of ambulance crews and volunteer firefighting organizations. Paramedics have more training than EMTs. Paramedics are not only able to stabilize patients, but they can begin treatments to cure patients, such as administering medication.

Office Professionals

Do you remember Hannah, the office manager from our previous example? Hannah is an example of an office professional. Without office managers and receptionists, many medical offices would grind to a halt! These people organize schedules, record appointments and answer patient questions. Office staff members have terrific communication and organization skills. They also must make a good first impression. The office manager may be the first person a patient sees upon entering a medical office, and the manager’s attitude can mean the difference between a pleasant visit and a nightmare for the patient.

EMTs can be ambulance crew members.

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Choose the best term to complete each sentence. Not all terms will be used. None of the terms will be used more than once.

office manager nurse’s assistants medical coder police officers

firefighters physician nurse paramedics

medical billing specialists medical transcriptionist

1. The ____________________________________________ completes many years of college and special medical training and must complete one or more residencies.

2. ______________________________________ _____________________________ help nurses with daily duties, such as paperwork and general organization.

3. To bill insurance companies, ______________________________________ _______________________________________ ____________________________ use codes that the medical coding specialist assigns.

4. The person who listens to recorded physician notes and types them to add to a patient’s file is the ____________________________ _________________________________________.

5. ______________________________________________________ have more training than EMTs and not only are able to stabilize patients but also begin treatments to cure patients.



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Step 9 Welcome to Your Career as a Medical Coding Specialist!

Now that you know the job duties of many of those in the healthcare world, let’s talk about the role that you, the medical coding specialist, will play in the healthcare picture. From the scenario you read at the beginning of this lesson, you know that you will be responsible for assigning medical codes to the information obtained from a patient’s visit to a medical facility. As the coding specialist, you get the medical record the physician dictated that we talked about previously. You look over the complaint, the diagnosis and the treatment performed, and then you code appropriately. To code, you look up the information in a reference book and find the right set of numbers that describes exactly what occurred.

You can code at home or work in a doctor’s office or hospital, and some doctors use independent coding specialists. In fact, there are even companies that hire coding specialists across the country. These remote coders work online in distant locations, and the company finds work for them to code. So much depends on where and when you want to work. What’s exciting is that you’re in control—just as you are in this course, working toward your new career!

As you already know, medical coding specialists are in demand. Just by looking at the number of patients doctors see every day, you can imagine how many coders are needed. Every appointment needs a code attached!

Surveys indicate that many medical coding specialists earn $35,000 per year or more. In fact, some medical coding consultants make more than $100,000 per year. Of course, you shouldn’t expect to make $100,000 your first year. But with work and dedication, you can earn a tremendous salary in a short time.

Experienced medical coding consultants can earn impressive salaries.

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But Where Will I Work?

Someone with the knowledge you’re gaining in this course will not be limited to simply filling out forms. No, the world of medical coding is very diverse and, as you already know, it offers full- or part-time job opportunities, at home or in offices.


Mercy Medical Center is looking for a part-time Medical Coding Specialist to accurately assign codes to records. One year of coding experience is preferred, but those who can show they have real-world training in medical coding also will be considered. Mercy Medical Center is an equal opportunity employer.

Please send cover letter, resume and references to:Mercy Medical Center 111 Main Street Suite 1 Avery, Ohio 44444

Find Your Future as our Next Medical Coder!

Hart Family Practice is looking for a full-time medical coder to code medical records. Applicant must have knowledge of medical terminology, anatomy and medical codes. The position offers a generous benefit package, and salary is based upon experience. EOE

If interested in applying, please send a cover letter and resume to:Hart Family Practice222 Skinner Road Pittman, Louisiana 23232

Medical coding specialists no longer are restricted to the doctor’s office but now work in hospitals, pharmacies, nursing homes, mental healthcare facilities, rehabilitation centers, insurance companies, consulting firms, health data organizations and their homes. And remember, if you decide you want to work at home, you set your own work schedule and save on items such as child daycare and transportation. So how is it possible that one career offers so many choices? Let’s take a closer look at two different jobs available to you in this career.

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A coding specialist typically works in an office or hospital. In some cases the physician assigns the code, and the coding specialist simply verifies that these codes are consistent with what the physician has documented. In other cases the doctor does not assign codes. Instead, the medical coding specialist translates the doctor’s written diagnosis and treatment into codes. Then the coder often routes the codes to a medical billing specialist who sends the claim to the insurance company.

For example, a medical coder working for a radiologist might have a super bill indicating a patient came in for a broken finger, as well as transcription documenting how the x-ray was performed and the radiologist’s reading of the x-ray. The medical coder would apply the correct codes for the diagnosis and the procedure, and the medical billing specialist then would send these codes to the insurance company.

The Medical Coding Service

A medical coding service is the most common at-home employment opportunity for a medical coding specialist. Medical coding service providers use a computer to complete the necessary forms and submit them to the office manager or medical billing specialist. Typically, the self-employed medical coding specialist charges by the medical record and has more than one provider as a client.

The work of an independent medical coder doesn’t vary much from that of those who work in offices and hospitals. The biggest difference involves how the work gets to and leaves the medical coding specialist. If the coding service does work for local providers, the work could be picked up and dropped off every 24 to 48 hours. The medical coding specialist simply takes the information home, codes it and then returns it to the physician’s office. If the physician is having his transcription done online, he is set up for online communication of all work. The coding work can be exchanged online. The great thing about this route is the medical coding specialist isn’t limited to clients in her town or even state!

If you’re going to do your medical coding work from home, there are several items to consider. You’ll have to purchase equipment and set up a home office, as well as market yourself to find clients. Consult the Medical Coding Specialist Career Starter Kit included in this course for more guidance in setting up a home-based business. For now, let’s talk a bit about the personal qualities that medical coding specialists should possess.

Medical coders apply codes for x-rays.

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Step 10 Personal Qualities of a Medical Coder

If you think about it, there are a large number of potential clients available in most towns. Even small towns usually have one or two doctor’s offices and a hospital. Many times qualified help is hard to find, and because you have a skill that is in great demand, you have the opportunity to make good money. Though salaries vary depending on experience, the number of hours worked and location, we think you’ll be pleased to discover the amount of money you can earn as a medical coding specialist. And remember that as your experience builds, you can add to your earnings while being a vital part of a medical team and doing work that helps people.

As a part of the healthcare team, medical coders do much of their work alone; however, coders still are a vital part of that team. The main thing to remember when you approach a potential client or employer is that you are the best medical coding specialist for the job. Your competence means money—their livelihoods—to your employers! Coders should remember and practice three qualities: professionalism, presentation and adaptability.

Professionalism

Professionalism is the conduct, aim or qualities that characterize a profession or professional person. As with any business, the image you project is important. You must be professional. This includes how you dress, talk and interact with your clients. When you have an initial meeting with potential clients, your level of professionalism will affect their impression of you.

When you select what to wear, be conservative but not bland. Your attire should be clean, wrinkle free and professional. Try to choose something you feel comfortable wearing. If you are comfortable, you will be able to concentrate on other important things such as your presentation and answering any questions your potential client may have. An uncomfortable outfit, whether in style, color or both, will distract you.

Another facet of professionalism is delivering what you promise. You’ve probably heard the saying, “Five minutes early is 10 minutes late.” Basically, this means if you have a meeting at 10 a.m., be 15 minutes early. Never be late, especially for a first-time interview. Such promptness shows you are responsible and considerate. If your client is a little late, be understanding. Just make sure you aren’t the tardy one. When you are asked for work samples, be prepared. Explain what you know and how you gained your knowledge. If you ever are asked to complete a test task, do so promptly.

As with any business, the image you

project is important.

When you select what to wear, be conservative

but not bland.

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Presentation

Presentation is the act of bringing or introducing something into the presence of someone else. Often your initial presentation will decide whether you gain a client or employer. In addition to being on time and dressed properly for the meeting, your presentation can go a long way in influencing your client-to-be—both positively and negatively.

Be sure to present a confident image. Your attitude should say, “I know what I’m doing” without being arrogant or condescending. Remember, this is the client’s money you’re talking about. Confidence is a must!

Adaptability

Adaptability is the ability to be modified or changed. To be successful, you must be able to adapt for each client. Some people want tasks done a certain way. Others may have exactly the opposite requirements. Insurance regulations change. Forms are altered. If you get too set in your ways, you might lose clients who require slightly different approaches.

Step 11 Medical Records

We’ve all had experiences with a doctor’s office. You’ve probably been asked to fill out a new patient questionnaire in a doctor’s waiting room, or maybe you’ve called to reschedule a dentist appointment. But you may not be familiar with the contents of a medical record. Let’s clear up some of these mysteries. As a coder, you’ll become a pro at explaining these contents.

A medical record is generated when a patient receives medical care. This record usually begins its life as a questionnaire or patient data sheet—like the one the new patient filled out in our example. The questionnaire asks about a patient’s medical history, insurance coverage and other important facts. After the patient completes the form, the office administrator takes it and any applicable insurance information and enters all of this into the office’s database, either on a computer or manually in a file cabinet. Then a medical file or record is created.

The medical record contains all of a patient’s medical history related to that doctor and his office. The medical file includes charts, notes and information to identify the patient, support the diagnosis or reason for the appointment, justify the treatment and accurately document the results. The record also contains past and present illnesses and treatments. Every aspect of a patient’s treatment at a healthcare facility is documented in this file. In other words, the medical record provides a complete picture of the health care the patient has received.

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Parts of a Medical Record

The most common parts of a medical record include: The patient questionnaire, registration/admission form, consent for treatment form, patient history form, plan of treatment form and progress report form. Let’s take a moment to discuss each of these briefly, as well as look at a few examples.

Questionnaire

A medical record is generated when a patient receives medical care. This record usually begins its life as a questionnaire or patient data sheet. The questionnaire asks about a patient’s medical history, insurance coverage and other important facts.

Let’s take a look at an example questionnaire.

Patient Data Sheet

Patient Name: Date: Last: First: MI: Street/P.O.: City/State: Zip Code: Sex: M F Birthdate: SS #: Patient Home Phone: Patient Work Phone: Primary Care Physician: Bill To: (Head of Household If Different From Above Information) Last Name: First: MI: Birthdate: SS #: Street/P.O.: City/State: Zip Code: Work Phone: Home Phone: Head of Household Place of Employment: Message Phone: Primary Insurance Coverage: Company: ID #: Group #: 2nd Insurance Coverage: (If applicable) ID #: Group #: Spouse: (If applicable) Last: First: MI: Birthdate: SS #: Place of Employment: Work Phone: Children: (If a patient or will be a patient at this clinic, please list) Sex Last: First: Ml: M F Birthdate: Last: First: Ml: M F Birthdate: Last: First: Ml: M F Birthdate: Last: First: Ml: M F Birthdate: In case of emergency and I am unavailable, you have my permission to treat any of the members of my family as necessary. Signature: Date:

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Registration/Admission

The registration/admission form is used to record important information, such as the patient’s name, address and insurance information. This form may be completed every time a patient sees the provider, or the practice may keep one on file and update it as necessary.

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Consent for Treatment Form

Whenever a patient agrees to a suggested treatment, the patient must complete a consent for treatment form. The consent for treatment form includes a statement indicating the patient has been informed of the treatment plan, including possible side effects and negative outcomes. The patient signs the form, indicating agreement to the treatment and awareness of all possible consequences resulting from the treatment.

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Medical Coding

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Consent fConsent fConsent fConsent fConsent for Tor Tor Tor Tor Treatment Freatment Freatment Freatment Freatment Formormormormorm

Whenever a patient agrees to a suggested treatment, the patient mustcomplete a consent for treatment form. The consent for treatmentform includes a statement indicating the patient has been informed of thetreatment plan, including possible side effects and negative outcomes. Thepatient signs the form, indicating agreement to the treatment andawareness of all possible consequences resulting from the treatment.

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Patient History

When a patient sees a provider for the first time or hasn’t seen a particular doctor for a long period of time, the patient is asked to fill out a patient history form. The patient history contains critical questions regarding the patient’s health history. The patient’s responses to these questions enable the doctor and medical staff to give the patient the best possible care.

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PPPPPatient Histatient Histatient Histatient Histatient Histororororory Fy Fy Fy Fy Formormormormorm

When a patient sees a doctor for the first time or hasn’t seen a particulardoctor for a long period of time, the patient is asked to fill out a patienthistory form. The patient history form contains critical questions regardingthe patient’s health history. The patient’s responses to these questions enablethe doctor and medical staff to give the patient the best possible care. Ifyou’ve been to a doctor, you’ve filled out one of these forms.

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Plan of Treatment Form

The doctor records the orders given to the patient regarding treatment on the plan of treatment form. In our example, the physician’s instructions are for discharging the patient. Completion of this form helps establish a plan for recovery and provides the patient with clear instructions to follow.

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Plan of TPlan of TPlan of TPlan of TPlan of Treatment Freatment Freatment Freatment Freatment Formormormormorm

The doctor records the orders given to the patient regarding treatment onthe plan of treatment form. In our example, the physician’sinstructions are for discharging the patient. Completion of this form helpsestablish a plan for recovery and provides the patient with clearinstructions to follow.

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Progress Report Form

As a treatment plan moves along, or as a patient’s condition changes, the information is recorded on the progress report form. Providers use this form to chart changes of all kinds in their patients’ conditions. Changes can include worsening conditions as well as improvements. Every patient has a progress report form.

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The Flow of Medical Information

Doctors, nurses and other health professionals use the medical record to provide patient information for the different segments of the patient’s care. The record helps the various practitioners involved in treating the patient to communicate with one another. It’s not necessary for a doctor to individually speak with each healthcare professional. The medical record keeps the current healthcare providers abreast of the patient’s treatment and progress. In addition, the record depicts for future providers an accurate picture of the patient’s previous care. It enables one doctor who takes over for another to continue to treat the patient without interrupting care.

Another important use of the medical record is for reimbursements. The patient’s file supplies information so the patient and third-party payers can be billed for services and expenses. The medical record substantiates laboratory tests, medications and other services listed on an insurance claim.

The medical record serves other purposes as well. It’s a legal business record for the healthcare provider. It gives the patient documentation with which to make legal claims—for example, the extent of injuries from an auto- or work-related accident. The record can be used to analyze and review the quality of patient care. It also can be used for research and education and for healthcare facility planning and market research. And medical records help determine problems that the healthcare delivery system needs to address, such as increases in the occurrence of heart disease or breast cancer.

Medical records first were kept in hospitals. Now, virtually every healthcare provider maintains such records because complete files are necessary to verify medical expenses, validate the healthcare provided and meet government requirements. Although different types of healthcare providers maintain medical records, all records still are patterned after the hospital medical record. The format used, and the information recorded in each record is similar from one facility to another. The box that follows summarizes the purpose of the information that medical records provide.

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Medical Records:

• Identify the patient

• Record results of tests and treatments

• Justify diagnoses and treatments

• Offer information to all providers involved in the patient’s care

• Detail the patient’s previous care for future providers

• Maintain a record of services for billing third-party payers

• Provide the healthcare facility with a legal business record

• Provide tools for evaluating patient care

• Provide documentation for study and research

• Give healthcare providers data for planning delivery of services and marketing


Choose the best answer from the choices provided.

1. Some medical coders work _____ in distant locations.a. with medical billing specialists

b. online

c. long hours

d. by phone

2. When coding a patient’s visit to a doctor, which of these is something the coding specialist codes for? _____a. The time the patient spent in the waiting room

b. The time it took for the doctor to arrive in the examination room

c. The main reason the patient saw the doctor

d. What the patient was wearing

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3. A medical record _____.a. is generated when a patient receives medical care

b. usually begins its life as a questionnaire or patient data sheet

c. provides a complete picture of the health care the patient has received

d. all of the above

4. Which of the following is NOT an important use of a medical record? _____a. It’s a legal business record for the healthcare provider.

b. It can be used for research and education.

c. It can be used to train doctors.

d. It’s used for reimbursement.

5. _____ justify diagnoses and treatments and detail the patient’s previous care for future providers.a. Flow charts

b. Admissions records

c. Questionnaires

d. Medical records

6. The format used and kinds of information recorded in each medical record is _____ from one facility to another. a. similar

b. exactly the same

c. very different

d. often lost when the record is transferred



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Step 14 Lesson Summary

Medical coders are an important part of any medical setting, and the scenario at the beginning of this lesson showed you how information flows through such settings. This lesson also gave you a firm understanding as to what each member of the healthcare team does. Coders work with physicians, nurses, office managers and others to contribute to the best possible patient care. You learned that this care occurs in a three-part sequence: chief complaint, diagnosis and treatment. The diagnosis and treatment eventually are coded by you, the medical coding specialist!

We also discussed a few important points for you to remember as you move toward your new career. You learned about possible employment opportunities and settings. You also learned the importance of professionalism, presentation and adaptability.

Lastly, this lesson discussed medical records. The medical coding specialist works closely with medical records to assign the correct codes for the diagnosis and procedure determined during a patient visit. The accuracy of the codes determines correctly completed insurance forms, thereby obtaining the proper reimbursement for the doctor.

As you continue this course, you’ll see in greater detail just how important medical coding specialists are to those who work in and rely on medical facilities. Medical coding specialists are in demand! The entire field is expected to grow by more than 46 percent, and the projected growth for those coders working directly for physicians is 94 percent! By choosing this course, you have started on an exciting path toward success. You are now ready to complete your first Mail-in Quiz.

Step 15 Mail-in Quiz 1

Follow the steps to complete the Quiz.

a. Be sure you’ve mastered the instruction and the Practice Exercises that this Quiz covers.

b. Mark your answers on your Quiz. Remember to check your answers with the lesson content.

c. When you’ve finished, transfer your answers to the Scanner Answer Sheet included. Use only blue or black ink on your Scanner Answer Sheet.

d. Important! Please fill in all information requested on your Scanner Answer Sheet or when submitting your Quiz online.

e. Submit your answers to the school via mail, fax or, to receive your grade immediately, submit your answers online at www.uscareerinstitute.edu.

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Mail-in Quiz 1

Choose the best answer from the choices provided. Each item is worth 5 points.

1. The number of steps in the sequence beginning with the patient’s complaint is _____, not including any tests that might be done.a. 3

b. 4

c. 5

d. 7

2. One reason medical coding specialists are in demand is _____.a. coding specialists can operate as doctors operate

b. there are many doctors and patients throughout the United States

c. there are only a few medical terms

d. the medical bill is generally very complex

3. During residency, physicians might be asked to work _____ hours per week.a. 200

b. 150

c. 85-100

d. 1000

4. The _____ assists the doctor by carrying out instructions under the doctor’s supervision.a. nurse’s assistant

b. EMT

c. paramedic

d. physician assistant

5. _____ complete insurance forms and ensure proper reimbursement for patient encounters.a. Accounts receivable specialists

b. Medical billing specialists

c. Radiologic technologists

d. Medical record technologists

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6. Which of these lists correctly illustrates the order of training, from lowest to highest, of medical personnel? _____a. EMT, paramedic, physician

b. paramedic, EMT, physician

c. physician, EMT, paramedic

d. EMT, physician, paramedic

7. EMT personnel _____ patients, while paramedics might begin to cure them.a. perform surgery on

b. treat

c. stabilize

d. none of the above

8. The _____ organizes schedules and keeps appointments straight.a. office manager

b. laboratory technician

c. physician

d. nurse

9. A part of the patient’s visit you code for is the _____.a. doctor’s diagnosis

b. receptionist’s comments

c. nursing notes

d. money the patient paid

10. Which of these is NOT something you would code for? _____a. The time spent in the waiting room

b. Any tests medical professionals performed on the patient

c. The treatment of the complaint (such as casting a broken arm)

d. All of the above are coded

11. The most common at-home employment opportunity for the medical coding specialist is the _____.a. medical coding service

b. coding processor

c. medical coding software system

d. insurance adjuster

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12. When a physician assigns the code, the coding specialist simply _____.a. ignores the codes and reassigns new ones

b. verifies that these codes are consistent with what the physician has documented

c. disputes whatever the doctor did

d. calls the patient and asks what happened during the appointment

13. An independent coding specialist typically works _____.a. in a doctor’s office

b. in a hospital

c. in an insurance company office

d. at home

14. To give yourself the best chance of gaining a new client, you must remember and practice professionalism, adaptability and _____.a. preoccupation

b. insurance billing

c. presentation

d. altruism

15. The _____ form is used to record the patient’s name, address and insurance information.a. registration/admission

b. consent for treatment

c. progress report

d. patient history

16. Whenever a patient agrees to a suggested treatment, the patient completes a _____ form.a. registration/admission


c. plan of treatment

d. patient history

17. All the orders given to the patient regarding treatment are recorded by the doctor on the _____ form.a. patient history


c. progress report

d. plan of treatment

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18. A _____ form is completed the first time a patient sees a particular provider, or if the patient hasn’t seen this doctor for a long time.a. consent for treatment

b. progress report

c. patient history

d. plan of treatment

19. As a treatment plan moves along, or as a patient’s condition changes, the information is recorded on the _____ form.a. consent for treatment

b. plan of treatment

c. patient history

d. progress report

20. _____ first were kept in hospitals. a. Test results

b. Flow charts

c. Patient history files

d. Medical records

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Congratulations!You have completed Lesson 1

Do not wait to receive the results of your Quiz before moving on.

Documents

The World of Health Care - Weston Distance Learning