Ancillary staff and/or patient documentation is the process of non-physicians and non-advanced practice providers (APPs) documenting clinical services, including history of present illness (HPI), social history, family history and review of systems in a patient’s electronic health record (EHR). Show
Ancillary staff regulatory mythWho on the care team can document components of E/M services and what is the physician required to do? Download the Myth (PDF) Historically, Medicare required the physician to redocument ancillary staff’s entries of the HPI to receive payment for the service. Further, Medicare had not issued guidance on the allowability of patient entries into the medical record. However, the Centers for Medicare and Medicaid (CMS) addressed these matters in the 2019 Calendar Year Physician Fee Schedule. Additional changes were made by CMS in 2021 that further simplified the requirements. The myth The mythPhysicians are required to redocument staff or patient entry in the patient record.* Debunking the myth Debunking the mythMedicare documentation requirements changed in November 2018 and now allow physicians to “verify” in the medical record staff or patient documentation of components of E/M services, rather than redocumentation of the work, if this is consistent with state and institutional policies. In January 2021 Medicare documentation requirements were further simplified: when billing by content (as opposed to time) medical decision making is the only component that drives the level of service determination. Regulatory clarification Regulatory clarificationStarting Jan. 1, 2021, the level of service is not determined by the history of present illness, social history, family history, review of systems or physical exam. These items may still warrant documentation for clinical purposes. There are no restrictions as to who can input this information into the patient’s record. Thus elements could be entered by the patient, a clerical assistant, a medical assistant or other clinician. Summary of changes Summary of changesThe 2021 Calendar Year Medicare Physician Fee Schedule allows a physician to determine the level of service based on either medical decision making (when billing by content) or by time. There is no requirement that the documentation be physically performed by the billing practitioner and no requirement to redocument information entered by a non-billing practitioner. Resources Resources
Debunking Regulatory Myths overview Debunking Regulatory Myths overviewVisit the overview page for information on additional myths. Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues. Interested in what administrative tasks and knowledge a medical assistant needs to be successful? The medical assistant manages multiple tasks and needs extensive administrative knowledge to perform their job responsibilities on a day-to-day basis. Medical Assistant Administrative TasksThe medical assistant does many different administrative tasks in the course of work each day, they include: • Schedule and monitor patient appointments using electronic health record database and paper-based systems
• Ensure that documentation complies with government and insurance requirements
• Manage electronic health records and paper medical records
• Enter information into databases or spreadsheets
• Participate in safety evaluations and report safety concerns Medical Assistant Administrative KnowledgeThe medical assistant learns knowledge to help them succeed in the medical field while attending a Medical Assisting Program. They must have knowledge of filing systems, scheduling software, telephone etiquette, records management, legal requirements, chart review, government regulations, advanced beneficiary notice, auditing methods, and data entry. Filing systems – a way in which files are named and where they are placed logically for storage and retrieval. Scheduling software – helps medical assistants manage appointments and bookings. Triage – recognition of urgency of appointment needs Requirements Related to Duration of Visit – the visit duration depends on the type of medical treatment, exam or procedure and how busy the medical professional is that the patient is seeing. Telephone Etiquette – it is important for the medical assistant to be consistently polite even when talking to unhappy customers. Calls should be answered as quickly as possible. Records Management Systems and Software – an organization through the medical records life-cycle including the control of the creation, maintenance, and destruction of medical records. Legal Requirements Related to Maintenance, Storage, and Disposal of Records – state laws or regulations define the requirements and conditions related to medical records. In the absence of these laws, the HIPPA privacy rule prevails. Categories of the Medical Record – they include administrative, clinical, billing, procedural, notes and consents. Required Documentation for Patient Review and Signature – the documentation should include the reason for the encounter, relevant history, findings, test results and date of service. It should also include the assessment and impression of the diagnosis and the plan of care with date and identity of observer. E-referrals – enable the seamless transfer of patient information from one physician to another. Financial Eligibility, Sliding Scales, and Indigent Programs – financial eligibility is based on the insurance plan chosen, plan premium, the deductible, co-pay and other medical costs. Government Medical Regulations – a rule of order having the force of law, prescribed by an authority, relating to the actions of those in the medical industry. Advanced beneficiary notice (ABN) – a waiver of liability or a notice a provider should give to the patient before they receive a service that their provider has reason to believe Medicare or insurance will not pay for. Specialty pharmacies – compounding and nuclear pharmacies that dispense radioactive materials for use in nuclear medicine. Insurance Terminology – a medical assistant must become familiar with insurance terms to process charts, insurance and help educate patients. Accounts Receivable – money owed to the medical facility by a patient or third-party vendor. Online Banking for Deposits and Electronic Transfers – a method of banking in which transactions are conducted electronically via the Internet. Authorizations to Approve Payment Processing – the approval of electronic debit or credit card transactions for payment by the issuer to the medical facility. Auditing Methods, Processes, and Sign-Offs Data Entry and Data Fields – the medical assistant should be proficient at QWERTY and 10-Key typing for proper charting, billing and management of electronic records. Enjoy being part of a team that cares about their patients? Want to become a medical assistant? PCI Health Training Center’s Medical Assistant programs prepares a graduate to work as an entry-level Medical Assistant. Within this general career category there are several specialty areas, including Medical Administrative Office Assistant, Clinic Assistant, Clinic Tech, Medical Office Manager, Phlebotomist, Physical Therapy Aide in a doctor’s office, clinic or hospital out-patient clinic. Contact PCI Health Training Center for more information on how to become a medical assistant and start a rewarding career today. **PCI firmly upholds its policy of nondiscrimination. Inquiries regarding policy may be directed to [email protected]. For more information about our graduation rates, the median debt of students who complete the program, and other important information, please visit our website at www.pcihealth.edu/consumer-information. What are the duties and responsibilities of a medical assistant quizlet?Take medical histories, take vital signs, assist doctor with medical procedures, examining treatment procedures for patients, examining treatment procedures, and preparing patients for and assiting examination.
Which of the following instructions should a medical assistant give to a patient about the use of a Holter monitor?Which of the following instructions should a medical assistant give to a patient about the use of a Holter monitor equipped with an event marker? "Press the marker when symptoms begin."
Which of the following should always be included when the medical assistant takes a message?If taking a message, it should include the name of the caller, who the message is for, the telephone number of the caller, the time and date of the call, and any message that needs to be conveyed.
Which of the following instructions should a medical assistant provide to a patient regarding a transdermal patch?Which of the following instructions should a medical assistant provide to a patient regarding transdermal patch use and care? Make sure to rotate patch placement to avoid skin irritation.
|