Read the scenario below and complete the tasks that follow.
Scenario
You just accepted a role as medical administrator at a podiatrist medical office. There are many responsibilities associated with this position including managing the office, patient registration, insurance verification/referrals, and scheduling following up appointments. As you navigate through your first day at work, the waiting room is full and a patient with a severe foot infection is seeking treatment without an appointment. As part of your new position and responsibilities, you will be required to review, assess, and participate in all medical administrative duties that will support this patient.
As the new medical administrator, you have will complete an encounter form of the new patient with a severe foot infection.
Identify and summarize the steps for registering this patient by completing the encounter form as the patient and the registration form as the medical administrator, which includes verification of the patient insurance. HIPAA privacy rule should be adhered when registering the patient.
In order to successfully complete the Outpatient Encounter Form and the Patient Registration Form below, please use the information contained in the following document:
Patient and Outpatient Information
- Patient Welcome/Managing Wait Time
In one page summarize how to greet the patient and manage the waiting room
Include a brief outline describing how to verify the patient’s insurance - Outpatient Encounter Form
Complete this form as the medical administrator: Outpatient Encounter Form
- Patient Registration Form
Complete this form as the patient: Patient Registration Form
- Apply HIPAA rules when documenting patient information
Outline the five steps under the HIPAA privacy rule to ensure patient information is protected while registering the patient. The summary should follow the “Guidelines for Ensuring” patient privacy isn’t breached in the reception area
Outpatient Encounter Form
Patient Information |
Billing Information |
Visit Information |
|||||
Patient ID number |
Primary |
Visit date |
|||||
Patient name |
Primary ID number |
Visit number |
|||||
Address |
Primary group number |
Rendering physician |
|||||
City/State |
Secondary |
Referring physician |
|||||
Social Security number |
Secondary ID number |
Reason for visit |
|||||
Phone number |
Secondary group no. |
||||||
Date of birth |
Cash/credit card |
||||||
Age |
Other billing |
||||||
E/M Modifiers |
Procedure Modifiers |
Other Modifiers |
|||||
24 — Unrelated E/M service during postop. |
22 — Unusual, excessive procedure |
||||||
25 — Significant, separately identifiable E/M |
50 — Bilateral procedure |
||||||
57 — Decision for surgery |
51 — Multiple surgical procedures in same day |
||||||
52 — Reduced/incomplete procedure |
|||||||
55 — Postop. management only |
|||||||
59 — Distinct multiple procedures |
|||||||
CATEGORY |
CODE |
MOD |
FEE |
||||
Office Visit — New Patient |
Wound Care |
||||||
Minimal office visit |
99201 |
Debride partial thick burn |
11040 |
||||
20 minutes |
99202 |
Debride full thickness burn |
11041 |
||||
30 minutes |
99203 |
Debride wound, not a burn |
11000 |
||||
45 minutes |
99204 |
Unna boot application |
29580 |
||||
60 minutes |
99205 |
Unna boot removal |
29700 |
||||
Other | |||||||
Office Visit — Established |
Supplies |
||||||
99211 |
Ace bandage, 2” |
A6448 |
|||||
10 minutes |
99212 |
Ace bandage, 3″-4” |
A6449 |
||||
15 minutes |
99213 |
Ace bandage, 6” |
A6450 |
||||
25 minutes |
99214 |
Cast, fiberglass |
A4590 |
||||
40 minutes |
99215 |
Coban wrap |
A6454 |
||||
Foley catheter |
A4338 |
||||||
General Procedures |
Immobilizer |
L3670 |
|||||
Anascopy |
46600 |
Kerlix roll |
A6220 |
||||
Audiometry |
92551 |
Oxygen mask/cannula |
A4620 |
||||
Breast aspiration |
19000 |
Sleeve, elbow |
E0191 |
||||
Cerumen removal |
69210 |
Sling |
A4565 |
||||
Circumcision |
54150 |
Splint, ready-made |
A4570 |
||||
DDST |
96110 |
Splint, wrist |
S8451 |
||||
Flex sigmoidoscopy |
45330 |
Sterile packing |
A6407 |
||||
Flex sig. w/ biopsy |
45331 |
Surgical tray |
A4550 |
||||
Foreign body removal—foot |
28190 |
||||||
Nail removal |
11730 |
OB Care |
|||||
Nail removal/phenol |
11750 |
Routine OB care |
59400 |
||||
Trigger point injection |
20552 |
OB call |
59422 |
||||
Tympanometry |
92567 |
Ante partum 4–6 visits |
59425 |
||||
Visual acuity |
99173 |
Ante partum 7 or more visits |
59426 |
Other Visit Information:
Fees:
Lab Work to Order:
Total Charges:
$
Referral to:
Copay Received:
$
Provider Signature:
Other Payment:
$
Next Appointment:
Total Due:
$
� MACROBUTTON DoFieldClick [Company Name]�
Company Name, Street Address, City, State ZIP Code, phone number
[NAME OF PRACTICE]
(Please Print)
Today’s date:
PATIENT INFORMATION
Patient’s last name: First: Middle: Mr.
Mrs.
Miss
Ms.
Marital status (circle one)
Single / Mar / Div / Sep / Wid
Is this your legal name? If not, what is your legal name? (Former name):
Yes No / / M F
Social Security no.: Home phone no.:
( )
P.O. box:
Employer phone no.:
( )
Chose clinic because/Referred to clinic by (please check one box): Dr. Insurance Plan Hospital
Family Friend Close to home/work Yellow Pages Other
INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)
Birth date: Address (if different): Home phone no.:
/ / ( )
Is this person a patient here? Yes No
Occupation: Employer:
Employer phone no.:
( )
Is this patient covered by
insurance? Yes No
Please indicate primary
insurance [Insurance] [Insurance] [Insurance] [Insurance] [Insurance]
[Insurance] [Insurance] [Insurance] Welfare (Please provide coupon) Other
Subscriber’s name: Subscriber’s S.S. no.: Birth date: Group no.: Policy no.: Co-payment:
/ / $
Patient’s relationship to subscriber: Self Spouse Child Other
Name of secondary insurance (if applicable): Subscriber’s name: Group no.: Policy no.:
Patient’s relationship to subscriber: Self Spouse Child Other
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):
Home phone no.: Work phone no.:
( ) ( )
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand
that I am financially responsible for any balance. I also authorize
or insurance company to release any information required
to process my claims.
Patient/Guardian signature Date
- [Name of Practice]
REGISTRATION FORM
- Todays date:
- Patients last name First Middle:
- salutation:
- salutation_2:
- Yes:
- No:
- If not what is your legal name:
- Former name:
- Social Security no:
- Home phone no:
- PO box:
- Employer phone no:
- Chose clinic becauseReferred to clinic by please check one box:
- Family:
- Friend:
- Close to homework:
- Other:
- Yellow Pages:
- Dr:
- Insurance Plan:
- Hospital:
- Birth date_2:
- Address if different:
- Home phone no_2:
- Is this person a patient here Yes No:
- :
- _2:
- Occupation_2:
- Employer_2:
- Employer phone no_2:
- Is this patient covered by insurance Yes No:
- _3:
- _4:
- Insurance:
- Insurance_2:
- Insurance_3:
- Insurance_4:
- Insurance_5:
- Welfare Please provide:
- Insurance_6:
- Insurance_7:
- Insurance_8:
- Other_2:
- Subscribers name:
- Subscribers SS no:
- Birth date_3:
- Group no:
- Policy no:
- Patients relationship to subscriber Self Spouse Child Other:
- _5:
- _6:
- _7:
- _8:
- Name of secondary insurance if applicable:
- Subscribers name_2:
- Group no_2:
- Policy no_2:
- Patients relationship to subscriber Self Spouse Child Other_2:
- _9:
- _10:
- _11:
- _12:
- Name of local friend or relative not living at same address:
- Date:
PCP:
Birth date:
Age:
Sex:
Street address:
City:
State:
ZIP Code:
Occupation:
Employer:
Other family members seen here:
Person responsible for bill:
Employer address:
Relationship to patient:
Module03
Course Project – Part 1
PATIENT REGISTRATION FORM
Practice – The People’s Clinic
Address – 1000 Town Square, Anytown Pennsylvania 54321
Phone – 555-741-8529
PATIENT INFORMATION
Patient – Mrs. Jane Doe
Married
Former name – Jane Smith
DOB – 01/01/1960
SSN
– 123-45-6789
Address – 123 Main Street, Anytown Pennsylvania 54321
Phone – 555-987-6543
Occupation – Nurse
Employer – The People’s Hospital
Employer Phone – 555-456-7890
Doctor referral to clinic
INSURANCE INFORMATION
Jane Doe is responsible for payment
Primary insurance is Blue Cross Blue Shield
Subscriber – Jane Doe
ID – 123123123
Grp – 00550055
No secondary insurance
IN CASE OF EMERGENCY
Suzie Smith (sister)
Home – 555-567-8910
Work – 555-678-9012
OUTPATIENT ENCOUNTER FORM
Jane Doe (chart #0987) saw Dr. Brown on 1-1-2015.
She is 5’5’’ tall and weighs 130 pounds
Her blood pressure was 120/70
Her pulse was 60
Her temperature was 98.6
This was her second visit with Dr. Brown after she was referred by Dr. White. She is seeing Dr. Brown
for adult onset IDDM (insulin dependent diabetes mellitus).
Jane’s visit was only for an office visit and laboratory tests. Dr. Brown spent 25 minutes with Jane at this
visit and ordered lab testing for Hemoglobin A1C. Jane needs to return to see Dr. Brown in 1 month.
When Jane checked out she gave the receptionist her encounter form which had the office visit at a cost
of $100. She paid the amount of her copayment which was $20.