COURSE NAME/NUMBER:Front Office Il MEDA 121

HOURS/CREDITS:2Credits

CLASS LOCATION/TIMES:Location:Building Room

Days:

Times:

PREREQUISITES:Front Office I/MEDA 120

COURSE DESCRIPTION:The responsibilities of today’s medical assistant are ever changing and expanding both in the clinical and administrative areas. This course provides a brief introduction to the fundamentals of coding and claim submission. Students are provided hands on experiences working with claims and the medical billing process.

INSTRUCTOR:

OFFICE HOURS/CONTACT INFORMATION:

Office Hours: 7:30-8:00 a.m.; 2:30-3:00 p.m.

(By appointment)

Office Location: Building B, Room

Phone: (425) 235-2352 Ext.

Email:

COURSE OBJECTIVES (Course Competencies):Upon successful completion of this course the student will be able to:

  1. Define key terms related to coding and the claims process.
  2. Explain the main differences between indemnity plans and managed care plans.
  3. Describe the medical office billing work flow.
  4. Define the various types of insurance coverage.
  5. List ten primary responsibilities of a medical insurance specialist.
  6. Compare medical ethics and etiquette.
  7. Discuss effects of health care claim errors on medical office routines.
  8. Discuss the importance of medical record documentation in the billing and payment process.
  9. Define the facts that are included in patients’ protected health information (PHI).
  10. Discuss the purpose of the HIPPA Privacy Rule, the HIPPA Security Rule and the HIPPA Electronic Health Care Transactions and Code Sets standards.
  11. Describe which PHI can be released without the patients’ authorization.
  12. Describe the purpose of a retention schedule.
  13. Discuss how to guard against potentially fraudulent situations.
  14. Explain how diagnostic coding affects the payment process.
  15. Label the primary diagnosis and coexisting conditions.
  16. Explain the ICD-9 CM format, and identify sections used by medical insurance specialists in physician practices.
  17. Identify the purposed and correct use of V and E codes.
  18. Use a five step process to analyze diagnoses and locate the correct ICD-9 CM code.
  19. Identify the purpose and format of the Current Procedural Terminology (CPT).
  20. Name the three key factors (components) that influence the selection of Evaluation and Management codes and discuss E/M code assignment steps.
  21. Compare and contrast referral and consultation services.
  22. Recognize surgical packages and laboratory panels that are coded as single procedures.
  23. Describe the two types of codes in the Health Care Common Procedure Coding (HCPCS) and discuss when they should be used.
  24. Find correct procedure codes using the CPT.
  25. Discuss the major types of health plans and how the various structures affect the payments that patients owe for medical services.
  26. Describe three ways in which payments to the physician are set.
  27. Compare the calculation of payments for participating and non-participating providers and describe how balance billing rules affect the charges that can be collected from the patients.
  28. List the types of charges that patients may be responsible for at the time of service.
  29. Describe the process of using medical billing programs to prepare health care claims.
  30. Discuss the patient information and physician or supplier section of the CMS 1500 claim.
  31. Briefly describe the information contained in the five major sections of the HIPPA claim.
  32. Compare billing provider, pay-to-provider, rendering provider, and referring provider.
  33. Discuss the importance and use of claim control numbers and line item control numbers on HIPPA claims.
  34. Identify the three major methods of electronic claim transmission.
  35. Describe the claim determination process used by health plans.
  36. Follow five steps to process RAs/EOBs from health plans.
  37. Discuss common reasons for and appeals of reduced and denied payments.
  38. Discuss the coordination of benefits process used to determine the patient’s primary and additional insurance coverage.
  39. Describe the patient billing and collection process.
  40. Be prepared to handle patients’ inquiries about insurance and billing problems.
  41. Discuss the history and structure of the Blue Cross and Blue Shield Association.
  42. Describe four key features of the Blue Cross and Blue Shield member plans.
  43. Compare the responsibilities of physicians who do and do not participate in Blue Cross and Blue Shield member plans.
  44. Explain the BlueCard Program.
  45. Explain the important data to obtain from a subscriber’s Blue Cross and Blue Shield card.
  46. State two reasons to complete claim forms within established time limits.
  47. Identify two parts of Medicare coverage.
  48. Discuss the fees that Medicare participating and non-participating physicians are allowed to charge.
  49. Explain the difference between an excluded service and a medically unnecessary service.
  50. Name four situations in which Medicare is the secondary payer.
  51. Identify two ways Medicaid programs vary from state to state.
  52. List the primary kinds of Medicaid benefits determined by federal law, and give examples of additional benefits that states may authorize.
  53. Explain two broad classifications of people who are eligible for Medicaid assistance.
  54. Explain four areas that need special attention when filing Medicaid claims.
  55. Explain who is eligible for TRICARE and CHAMPVA and how to verify eligibility.
  56. Discuss the programs offered to TRICARE beneficiaries.
  57. Describe the use of a non-availability statement in the TRICARE program.
  58. Explain where to file claims first when TRICARE and CHAMPVA beneficiaries are also covered by other insurance programs.
  59. Identify filing deadlines and time limits for responses to requests for additional information.
  60. Discuss what workers’ compensation insurance covers and which federal and state agencies administer the programs.
  61. List the five types of compensation that employees may receive for work-related illnesses and injuries.
  62. List five questions to ask the state compensation board about workers’ compensation regulations.
  63. Explain why medical information that pertains to a workers’ compensation case should be separated from the patient’s chart for diseases and disorders that are not work related.
  64. Discuss the purpose of disability compensation.
  65. Name the six major federal disability programs, and describe who is eligible for program benefits.
  66. Compare government and private disability plans.
  67. List eight types of information the physician should include in a medical report for the claims department of a disability

ATTENDANCE AND MAKE-UP POLICY: Throughout the Medical Assistant Program, an outstanding work ethic is emphasized and encouraged. Participation and professionalism are essential to your success as a student and as a Medical Assistant. Ten percent of your grade involves participation and professionalism. If you must be absent, make arrangements beforehand to have a fellow student obtain any handouts and reading assignments you miss.

You are also responsible for getting assignments from a fellow student by phone or email when you are absent in order to complete an assignment on time. The full attendance policy is outlined in your medical assistant packet.

NATURE OF THE COURSE: To accommodate a wide variety of learning and personal styles many different instructional approaches may be used including: lecture, group discussion, demonstrations, interactive exercises, role playing, video programs, computer based training, student research, self directed learning projects and collaborative teaching with Program Instructors.

COURSE OUTLINE: See supplemental document.

GRADING: Grades are based on the following weighted categories and assigned the corresponding decimal grade:

Homework10%

Quizzes20%

Mid Term/Paper30%

Final Exam30%

Professionalism/Participation10%

Grades are assigned as follows:

Decimal Grade / Grade Percent / Letter Grade Equivalent
4.0 / 100 / A
3.9 / 99 / A-
3.8 / 98
3.7 / 97
3.6 / 96 / B+
3.5 / 95
3.4 / 94
3.3 / 93
3.2 / 92 / B
3.1 / 91
3.0 / 90
2.9 / 89 / B-
2.8 / 88
2.7 / 87
2.6 / 86 / C+
2.5 / 85
2.4 / 84
2.3 / 83
2.2 / 82 / C
2.1 / 81
2.0 / 80

TEXT:Young-Adams, Alexandra P. Kinn’s The Administrative Medical Assistant, Seventh Edition. St. Louis, Missouri: Saunders Elsevier, 2011

Supplemental (Not Required): Newby, Cynthia. From Patient to Payment: Insurance Procedures for the Medical Office, Fifth Edition. Boston: McGraw Hill, 2008.

ADDITIONAL MATERIALS:

Pens: Blue or black ink; no erasable or gel pens

Pencils

Calendar for assignments

USB Drive to store work

RESOURCES:

EMERGENCY INSTRUCTIONS FOR INCLEMENT WEATHER: In case of weather closure of the RTC Campus, class will be cancelled. Call the school at (425) 235-2352 and choose option 9 for weather closure information. Information will also be available on the website ( and local television and radio stations.

CLASSROOM MANAGEMENT POLICIES:

Renton Technical College recognizes and values diversity between students on campus, including cultural diversity, diversity of age, life style, race, religion, and financial backgrounds. Students are expected to listen respectfully to others and conduct themselves professionally in the classroom, at clinical sites, and at all campus related activities.

Certain behaviors will not be tolerated. Students engaging in those behaviors will be asked to leave the classroom and appropriate disciplinary steps will be taken. Examples are:

  • Unprofessional or disruptive behavior
  • Sleeping in class
  • Inappropriate attire
  • Foul language
  • Sexual harassment

Cheating and Plagiarism: As outlined in the Allied Health Department Handbook, Renton Technical College has a zero tolerance policy towards cheating and plagiarism. If a fellow student observes what appears to be cheating on an exam, the instructor should be made aware of the situation. Appropriate disciplinary action will be taken. If the instructor observes a student cheating on a test, appropriate disciplinary action will also be taken.

Similarly, on a paper or presentation, if wording is taken directly from any source without giving credit to the source, the student will receive a zero (0) on that paper or presentation. When there is doubt, the instructor will make the final judgment on whether plagiarism has occurred.

Disciplinary action includes, but is not limited to, the student receiving a zero (0) on a test, paper or presentation up to and including immediate expulsion from the program.

Reading Assignments: The student is responsible for reading all assigned material prior to the lecture. Much more can be gained from the classroom discussion if there is some basic familiarity with the content.

Questions: If you do not understand something during a lecture and do not want to ask a question in front of the entire class, talk to your instructor or other students when there is free time within the classroom. (There will be frequent opportunities at the end of class sessions to get clarification)

Asking classmates questions while other classroom information is taking place is disruptive to the entire class and theinstructor. It also causes students to miss what is currently being discussed.

Quizzes: There will be quizzes given approximately once a week. A Pop Quiz could be given at any point when the instructor needs to evaluate how much information is being assimilated by the students. Pop Quizzes cannot be madeup.If you are absent on the day of a scheduled quiz, you must make up the quiz the day you return to school to receive credit. In addition, if you are more than 10 minutes late for a quiz you will need to make it up by arrangement with the instructor. The highest possible grade for a make-up quiz is 90%.

Mid Term and Final: There will be a mid-term given during week five. After mid terms, the student and instructor will meet and discuss progress as necessary. A final exam will be given during the last week of the quarter. You will lose one letter grade for every day the final examination is not taken from the date it is offered to the rest of the class.

Homework is due on the assigned date. Students submitting homework past the due date will receive a 10% reduction from the original point value of the assignment for each day the assignment is late.

Note: Information contained in this syllabus is subject to change.

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Front Office Procedures II

MEDA 121

April 2011