Table Of Contents:
Preface vii
Reviewers ix
Publisher's Acknowledgment x
Authors' Acknowledgments xi
User's Guide xii
Contents xv

SECTION I Introducion to Medical Assisting 1(2)

Unit One Understanding the Profession 3(44)

Medicine and Medical Assisting 4(16)

History of Medicine 6(3)

Ancient Medical History 6(1)

Modern Medical History 7(1)

Recent Medical History 8(1)

The American Health Care System 9(1)

The Medical Office 9(1)

Medical Specialties 9(1)

The Medical Assisting Profession 10(1)

What Is a Medical Assistant? 10(1)

Duties of a Medical Assistant 11(1)

Characteristics of a Professional Medical Assistant 11(1)

Members of the Health Care Team 12(2)

Physicians 12(1)

Physician Assistants 12(1)

Nurses 13(1)

Nurse Practitioners 13(1)

Allied Health Professionals 13(1)

The History of Medical Assisting 14(1)

Medical Assisting Education 14(1)

Medical Assisting Program Accreditation 14(1)

Medical Assisting Certification 15(1)

Certified Medical Assistant 16(1)

Registered Medical Assistant 16(1)

Medical Assisting and Related Allied Health Associations 16(1)

Association Membership 16(1)

Employment Opportunities 17(1)

Chapter Summary 18(1)

Critical Thinking Challenges 18(1)

Answers to Checkpoint Questions 18(1)

Websites 18(2)

Law and Ethics 20(27)

The American Legal System 22(1)

Sources of Law 22(1)

Branches of the Law 22(1)

The Rise in Medical Legal Cases 23(1)

Physician-Patient Relationship 23(6)

Rights and Responsibilities of the Patient and Physician 23(1)

Contracts 23(2)

Consent 25(2)

Releasing Medical Information 27(1)

Legally Required Disclosures 27(2)

Specific Laws and Statutes That Apply to Health Professionals 29(2)

Medical Practice Acts 29(1)

Licensure Certification, and Registration 30(1)

Controlled Substances Act 30(1)

Good Samaritan Act 30(1)

Basis of Medical Law 31(2)

Tort Law 31(1)

Negligence and Malpractice (Unintentional Torts) 32(1)

The Litigation Process 33(1)

Defenses to Professional Liability Suits 34(1)

Medical Records 34(1)

Statute of Limitations 34(1)

Assumption of Risk 34(1)

Res Judicata 34(1)

Contributory Negligence 34(1)

Comparative Negligence 34(1)

Immunity 34(1)

Defense for the Medical Assistant 35(1)

Respondeat Superior or Law of Agency 35(1)

Employment and Safety Laws 36(8)

Civil Rights Act of 1964, Title VII 36(1)

Occupational Safety and Health Act 36(1)

Other Legal Considerations 37(1)

Medical Ethics 38(1)

American Medical Association (AMA) Code of Ethics 38(1)

Medical Assistant's Role in Ethics 38(1)

American Association of Medical Assistants (AAMA) Code of Ethics 39(1)

Bioethics 39(1)

American Medical Association (AMA) Council on Ethical and Judicial Affairs 40(1)

Social Policy Issues 40(2)

Professional and Ethical Conduct and Behavior 42(1)

Ethical Issues in Office Management 42(2)

Chapter Summary 44(1)

Critical Thinking Challenges 44(1)

Answers to Checkpoint Questions 45(1)

Websites 45(2)

Unit Two Communicating With Patients 47(38)

Fundamental Communication Skills 48(16)

Basic Communication Flow 50(1)

Forms of Communication 50(2)

Verbal Communication 50(1)

Nonverbal Communication 51(1)

Active Listening 52(1)

Interview Techniques 52(2)

Reflecting 53(1)

Paraphrasing or Restatement 53(1)

Asking for Examples or Clarification 53(1)

Asking Open-Ended Questions 53(1)

Summarizing 54(1)

Allowing Silences 54(1)

Factors Affecting Communication 54(4)

Cultural Differences 54(2)

Stereotyping and Biased Opinions 56(1)

Language Barriers 57(1)

Special Communication Challenges 58(2)

Hearing-Impaired Patients 58(1)

Sight-Impaired Patients 58(1)

Speech Impairments 59(1)

Mental Health Illnesses 59(1)

Angry or Distressed Patients 59(1)

Children 60(1)

Communicating With a Grieving Patient or Family Member 60(1)

Establishing Positive Patient Relationships 60(3)

Proper Form of Address 61(1)

Professional Distance 61(1)

Teaching Patients 61(1)

Professional Communication 62(1)

Communicating With Peers 62(1)

Communicating With Physicians 62(1)

Communicating With Other Facilities 62(1)

Chapter Summary 63(1)

Critical Thinking Challenges 63(1)

Answers to Checkpoint Questions 63(1)

Websites 63(1)

Patient Education 64(21)

The Patient Education Process 66(2)

Assessment 66(1)

Planning 66(1)

Implementation 67(1)

Evaluation 67(1)

Documentation 68(1)

Conditions Needed for Patient Education 68(2)

Maslow's Hierarchy of Needs 68(1)

Environment 69(1)

Equipment 69(1)

Knowledge 69(1)

Resources 70(1)

Factors That Can Hinder Education 70(2)

Existing Illnesses 70(1)

Communication Barriers 71(1)

Age 71(1)

Educational Background 71(1)

Physical Impairments 71(1)

Other Factors 71(1)

Teaching Specific Health Care Topics 72(10)

Preventive Medicine 72(1)

Medications 72(1)

Nutrition 73(4)

Exercise 77(1)

Alternative Medicine 78(1)

Stress Management 79(2)

Smoking Cessation 81(1)

Substance Abuse 81(1)

Patient Teaching Plans 82(2)

Developing a Plan 82(1)

Selecting and Adapting Teaching Material 82(1)

Developing Your Own Material 83(1)

Chapter Summary 84(1)

Critical Thinking Challenges 84(1)

Answers to Checkpoint Questions 84(1)

Websites 84(1)

SECTION II The Administrative Assistant 85(2)

Unit Three Performing Administrative Duties 87(138)

The First Contact: Telephone and Reception 88(18)

Professional Image 90(1)

Importance of a Good Attitude 90(1)

The Medical Assistant as a Role Model 90(1)

Courtesy and Diplomacy in the Medical Office 91(1)

First Impressions 91(1)

Reception 91(7)

Definition of a Receptionist 91(1)

Duties and Responsibilities of the Receptionist 92(2)

Ergonomic Concerns for the Receptionist 94(1)

The Waiting Room Environment 94(4)

The End of the Patient Visit 98(1)

Telephone 98(3)

Importance of the Telephone in the Medical Office 98(1)

Basic Guidelines for Telephone Use 98(2)

Routine Incoming Calls 100(1)

Challenging Incoming Calls 100(1)

Procedure 5-1: Handling Incoming Calls 101(2)

Triaging Incoming Calls 102(1)

Taking Messages 102(1)

Outgoing Calls 102(1)

Procedure 5-2: Calling Emergency Medical Services 103(1)

Services and Special Features 103(1)

Chapter Summary 104(1)

Critical Thinking Challenges 104(1)

Answers to Checkpoint Questions 104(1)

Websites 105(1)

Managing Appointments 106(16)

Appointment Scheduling Systems 108(1)

Manual Appointment Scheduling 108(1)

Computerized Appointment Scheduling 109(1)

Types of Scheduling 109(2)

Structured Appointments 109(1)

Flexible Hours 110(1)

Open Hours 110(1)

Factors That Affect Scheduling 111(1)

Patients' Needs 111(1)

Providers' Preferences and Needs 111(1)

Physical Facilities 111(1)

Scheduling Guidelines 112(1)

New Patients 112(1)

Procedure 6-1: Making an Appointment for a New Patient 112(1)

Established Patients 113(1)

Procedure 6-2: Making an Appointment for an Established Patient 113(1)

Preparing a Daily or Weekly Schedule 114(1)

Patient Reminders 114(1)

Appointment Cards 114(1)

Telephone Reminders 114(1)

Mailed Reminder Cards 115(1)

Adapting the Schedule 115(2)

Emergencies 115(1)

Patients Who Are Acutely III 115(1)

Walk-in Patients 116(1)

Late Patients 116(1)

Physician Delays 116(1)

Missed Appointments 116(1)

Cancellations 117(1)

Cancellations by the Office 117(1)

Cancellations by the Patient 117(1)

Making Appointments for Patients in Other Facilities 117(1)

Referrals and Consultations 117(1)

Procedure 6-3: Making an Appointment for a Referral to Another Provider 118(2)

Diagnostic Testing 118(1)

Surgery 119(1)

When the Appointment Schedule Does Not Work 120(1)

Chapter Summary 120(1)

Critical Thinking Challenges 120(1)

Answers to Checkpoint Questions 120(2)

Written Communications 122(18)

Professional Writing 124(3)

Basic Grammar and Punctuation Guidelines 124(1)

Basic Spelling Guidelines 124(1)

Guidelines for Medical Writing 124(3)

Letter Development 127(5)

Components of a Letter 127(2)

Letter Formats 129(1)

Writing a Business Letter 130(1)

Types of Business Letters 131(1)

Memorandum Development 132(1)

Components of a Memorandum 132(1)

Sending Written Communication 133(1)

Procedure 7-1: How to Fold a Letter for a No. 10 Envelope 133(1)

Facsimile Machines 133(1)

Procedure 7-2: How to Fold a Letter for an Envelope With a Window 134(3)

Electronic Mail 134(1)

United States Postal Service 135(1)

Other Delivery Options 136(1)

Receiving and Handling Incoming Mail 137(1)

Types of Incoming Mail 137(1)

Opening and Sorting Mail 137(1)

Annotation 137(1)

Composing Agendas and Minutes 137(1)

Chapter Summary 138(1)

Critical Thinking Challenges 138(1)

Answers to Checkpoint Questions 138(1)

Websites 138(2)

Medical Records and Record Management 140(18)

Standard Medical Records 142(1)

Contents of the Record 142(1)

Electronic Medical Records 143(1)

Electronic Medical Record Security 143(1)

Other Technologies for Medical Record Maintenance 143(1)

Medical Record Organization 144(1)

Provider Encounters 144(1)

Documentation Forms 145(1)

Medical History Forms 145(1)

Flow Sheets 145(1)

Progress Notes 145(1)

Medical Record Entries 145(4)

Charting Communications With Patients 149(1)

Additions to Medical Records 149(1)

Workers' Compensation Records 149(1)

Medical Record Preparation 150(1)

Procedure 8-1: Preparing a Medical File 150(1)

Filing Procedures 151(1)

Filing Systems 151(2)

Alphabetic Filing 151(1)

Numeric Filing 152(1)

Other Filing Systems 152(1)

Classifying Medical Records 153(1)

Inactive Record Storage 153(1)

Storing Active Medical Records 153(1)

Record Retention 154(1)

Releasing Medical Records 154(1)

Releasing Records to Patients 155(1)

Reporting Obligations 155(1)

Chapter Summary 155(1)

Critical Thinking Challenges 155(1)

Answers to Checkpoint Questions 155(3)

Transcription 158(20)

Medical Transcription 160(1)

The Transcription Process 160(1)

Off-site Transcription 160(1)

Report Formatting 160(1)

Procedure 9-1: Transcribing a Medical Document 161(1)

Types of Medical Reports 162(9)

History and Physical Examination Reports 162(1)

Consultation Reports 162(2)

Progress Reports 164(1)

Hospital Reports 164(7)

Transcription Rules 171(4)

Abbreviations 171(1)

Capitalization 171(1)

Numbers 171(1)

Punctuation 172(2)

Grammar 174(1)

Spelling 174(1)

Transcription Systems 175(1)

Traditional Tape Dictation Systems 175(1)

Digital Systems 175(1)

Voice Recognition Systems 175(1)

Transcription With Word Processing Software 176(1)

Chapter Summary 176(1)

Answers to Checkpoint Questions 176(1)

Websites 177(1)

Computer Applications in the Medical Office 178(18)

The Computer 180(1)

Hardware 180(1)

Peripherals 181(1)

Care and Maintenance of the System and Equipment 181(1)

Internet Basics 181(2)

Getting Started and Connected 181(1)

Security 182(1)

Viruses 182(1)

Downloading Information 182(1)

Working Offline 182(1)

Electronic Mail 183(1)

Access 183(1)

Composing Messages 183(1)

Address Books 183(1)

Attachments 183(1)

Opening Electronic Mail 184(1)

Medical Applications of the Internet 184(1)

Search Engines 184(1)

Procedure 10-1: Searching the Internet 185(1)

Professional Medical Sites 185(1)

Patient Teaching Issues Regarding the Internet 186(2)

Intranet 188(1)

Medical Software Applications 188(4)

Clinical Applications 189(1)

Administrative Applications 190(2)

Handheld Computers 192(1)

Purchasing a Computer 192(1)

Training Options 192(1)

Computer Ethics 192(1)

Chapter Summary 193(1)

Critical Thinking Challenges 193(1)

Answers to Checkpoint Questions 193(1)

Websites 194(2)

Quality Improvement and Risk Management 196(14)

Quality Improvement Programs in the Medical Office Setting 198(4)

Regulatory Agencies 198(4)

Developing a Quality Improvement Program 202(1)

Seven Steps for a Successful Program 202(1)

Risk Management 203(4)

Incident Reports 203(1)

When to Complete an Incident Report 203(1)

Information Included on an Incident Report 203(1)

Guidelines for Completing an Incident Report 204(1)

Trending Incident Reports 204(3)

Putting It All Together: A Case Review 207(1)

Chapter Summary 208(1)

Critical Thinking Challenges 208(1)

Answers to Checkpoint Questions 208(1)

Websites 208(2)

Management of the Medical Office Team 210(15)

Overview of Medical Office Management 212(1)

Organizational Structure 212(1)

The Medical Office Manager 212(1)

Responsibilities of the Medical Office Manager 213(6)

Communication 213(1)

Staffing Issues 214(4)

Policy and Procedures Manuals 218(1)

Procedure 12-1: Creating a Procedures Manual 219(3)

Developing Promotional Materials 221(1)

Financial Concerns 221(1)

Maintenance and Inventory of Supplies 221(1)

Education 222(1)

Legal Issues Regarding Office Management 222(1)

Americans with Disabilities Act 222(1)

Sexual Harassment 222(1)

Family and Medical Leave Act 222(1)

Other Legal Considerations 223(1)

Chapter Summary 223(1)

Critical Thinking Challenges 223(1)

Answers to Checkpoint Questions 223(1)

Websites 223(2)

Unit Four Managing the Finances in the Practice 225(82)

Credit and Collections 226(8)

Fees 228(1)

Fee Schedules 228(1)

Discussing Fees in Advance 228(1)

Forms of Payment 229(1)

Payment by Insurance Companies 229(1)

Adjusting Fees 229(1)

Credit 229(1)

Extending Credit 229(1)

Legal Considerations 229(1)

Collections 229(4)

Legal Considerations 230(1)

Collecting a Debt 230(3)

Collection Alternatives 233(1)

Chapter Summary 233(1)

Critical Thinking Challenges 233(1)

Answers to Checkpoint Questions 233(1)

Websites 233(1)

Bookkeeping and Banking 234(16)

Daily Bookkeeping 236(1)

Manual Accounting 236(1)

Pegboard Bookkeeping System 236(1)

Procedure 14-1: Balancing the Day Sheet 237(4)

Posting a Charge 239(1)

Posting a Payment 239(1)

Posting a Credit 239(1)

Posting a Credit Adjustment 239(1)

Posting a Debit Adjustment 239(2)

Procedure 14-2: Posting Charges to the Patient's Account 241(1)

Procedure 14-3: Posting Payments to a Patient's Account 241(1)

Procedure 14-4: Posting a Credit Adjustment 242(1)

Posting to Cash-Paid-Out Section of Day Sheet 242(1)

Computer Accounting 243(1)

Posting to Computer Accounts 243(1)

Computer Accounting Reports 243(1)

Banking 243(3)

Banks and Their Services 243(1)

Bank Fees 244(1)

Types of Checks 244(1)

Writing Checks for Accounts Payable 244(1)

Receiving Checks and Making Deposits 245(1)

Reconciling Bank Statements 246(1)

Petty Cash 246(1)

Procedure 14-5: Reconciling a Bank Statement 247(1)

Chapter Summary 248(1)

Critical Thinking Challenges 248(1)

Answers to Checkpoint Questions 248(1)

Websites 248(2)

Accounts Payable and Payroll 250(12)

Accounting Cycle 252(1)

Record-Keeping Components 252(1)

Accounts Payable 253(2)

Ordering Goods or Services 253(1)

Receiving Supplies 253(1)

Paying Invoices 253(2)

Payroll 255(1)

Types of Payroll Systems 255(1)

Procedure 15-1: Issuing a Payroll Check Using the Pegboard System 256(2)

Employee Records 257(1)

Tax Withholdings 257(1)

Procedure 15-2: Calculate the Amount of an Employee's Payroll Check 258(1)

Preparation of Reports 259(1)

Assisting With Audits 260(1)

Chapter Summary 260(1)

Critical Thinking Challenges 260(1)

Answers to Checkpoint Questions 260(1)

Websites 260(2)

Health Insurance 262(16)

Health Benefits Plans 264(3)

Group Health Benefits 264(1)

Individual Health Benefits 265(1)

Government-Sponsored (Public) Health Benefits 265(2)

Managed Care 267(4)

Health Maintenance Organizations 268(1)

Preferred Provider Organizations 269(1)

Physician Hospital Organizations 270(1)

Other Managed Care Programs 270(1)

The Future of Managed Care 271(1)

Workers' Compensation 271(3)

Filing Claims 274(1)

Electronic Claims Submission 274(1)

Explanation of Benefits 275(1)

Policies in the Practice 275(2)

Chapter Summary 277(1)

Critical Thinking Challenges 277(1)

Answers to Checkpoint Questions 277(1)

Websites 277(1)

Diagnostic Coding 278(16)

Diagnostic Coding 280(1)

Inpatient Versus Outpatient Coding 280(1)

ICD-9-CM: The Code Book 281(4)

Volume 1: Tabular List of Diseases 281(3)

Volume 2: Alphabetic Index to Diseases 284(1)

Volume 3: For Inpatient Coding 285(1)

Locating the Appropriate Code 285(6)

Using the ICD-9-CM Conventions 285(1)

Main Term 286(1)

Fourth and Fifth Digits 286(1)

Primary Codes 287(1)

When More Than One Code Is Used 287(3)

Coding Suspected Conditions 290(1)

Documentation Requirements 291(1)

The Future of Diagnostic Coding: International Classification of Diseases, Tenth Revision 291(1)

Chapter Summary 291(1)

Critical Thinking Challenges 291(1)

Answers to Checkpoint Questions 291(1)

Websites 292(2)

Outpatient Procedural Coding 294(13)

Physician's Current Procedural Terminology 296(7)

Reading Descriptors 296(1)

Guidelines 296(1)

Evaluation and Management Codes 297(2)

Anesthesia Codes 299(1)

Surgery Codes 300(1)

Radiology Codes 301(1)

Pathology and Laboratory Codes 301(1)

Medicine Codes 302(1)

CPT-4 Modifiers 302(1)

Healthcare Common Procedure Coding System (HCPCS) 303(1)

HCPCS Level 1 Codes 303(1)

HCPCS Level 2 Codes: National Codes 303(1)

HCPCS Level 3 Codes: Local Codes 303(1)

Reimbursement 303(1)

Diagnostic Related Groups 303(1)

Resource-Based Relative Value Scale 304(1)

Fraud and Coding 304(1)

Chapter Summary 305(1)

Critical Thinking Challenges 305(1)

Answers to Checkpoint Questions 305(1)

Websites 305(2)

SECTION III Career Strategies 307(2)

Unit Five Competing in the Job Market 309(20)

Making the Transition: Student to Employee 310(19)

Externships 312(3)

Types of Facilities 312(1)

Benefits of Externship 312(1)

Responsibilities of Externship 313(1)

Guidelines for a Successful Externship 313(2)

Externship Documentation 315(1)

Establish the Job for You 315(2)

Setting Employment Goals 315(1)

Self-Analysis 316(1)

Finding the Right Job 317(1)

Applying for the Job 318(3)

Answering Newspaper Advertisements 318(1)

Preparing Your Resume 318(3)

Preparing Your Cover Letter 321(1)

Completing an Employment Application 321(1)

Interviewing 321(2)

Preparing for the Interview 322(1)

Crucial Interview Questions 322(1)

Follow-up 323(2)

Why Some Applicants Fail to Get the Job 324(1)

Keep the Job or Move on? 325(1)

Employment Laws 325(1)

Chapter Summary 326(1)

Critical Thinking Challenges 326(1)

Answers to Checkpoint Questions 327(1)

Websites 327(2)

Appendices 329(14)

Appendix A: Medical Assisting Role Delineation Chart 330(2)

Appendix B: Key English-to-Spanish Health Care Phrases 332(5)

Appendix C: Two-Letter Postal ZIP Code Abbreviations 337(1)

Appendix D: Abbreviations Commonly Used in Documentation 338(3)

Appendix E: Commonly Misused Words 341(2)
Glossary of Key Terms 343(8)
ESL Glossary 351(8)
Index 359