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Pick and choose what you need from this thorough Policies & Procedures Manual. This downloadable manual includes the following: 

 

Policy and Procedure Manual

Table of Contents

 

CHAPTER 1:  POLICY DEVELOPMENT AND MAINTENANCE                                      Policy #

Development and Administration.......................................................................................... 105

Forms........................................................................................................................................... 110

 

CHAPTER 2:  PERSONNEL

Salary Determination................................................................................................................. 200

Provider Time Out .................................................................................................................... 205

Orientation and Training.......................................................................................................... 215

Performance Evaluations.......................................................................................................... 220

SMART Performance Evaluations........................................................................................... 221

Job Shadowing............................................................................................................................ 222

Mentoring Program................................................................................................................... 223

Property/Equipment Usage..................................................................................................... 225

Co-worker / Department Recognition Award...................................................................... 235

Patient Recognition Award……………………………………………………………………236

Staff Uniforms…………………………………………………………………………………..240

Employee Courtesy Discounts................................................................................................. 245

Reimbursed Expenses................................................................................................................ 250

Waiver of Health Insurance...................................................................................................... 255

Time Clock Instructions............................................................................................................ 260

PTO Cash Out............................................................................................................................. 265

Donating PTO............................................................................................................................. 270

Secondary Employment/Treatment or Services Outside of {YOUR  PRACTICE}.......... 275

 

 

CHAPTER 3:  APPOINTMENT SCHEDULING

General Appointment Scheduling Overall Guidelines........................................................ 300

Appointment Scheduling.......................................................................................................... 305

Notes in Drawer………………………………………………………………………………..306

Appointment Override.............................................................................................................. 310

Delinquent Balance Appointment........................................................................................... 315

Appointment Status................................................................................................................... 320

Missed Appointments --- see Policy 580 under Patient Communication

Appointment Reminders.......................................................................................................... 330

Appointment Scheduling Protocols........................................................................................ 335

Preparing for Daily Appointments.......................................................................................... 340

Late Arrivals............................................................................................................................... 345

Follow-up Appointments.......................................................................................................... 350

Cancellations............................................................................................................................... 355

Waiting Lists............................................................................................................................... 360

Reschedule List........................................................................................................................... 365

Call Triage and Scheduling...................................................................................................... 370

Urgent Care Guidelines............................................................................................................. 375

 

CHAPTER 3:  APPOINTMENT SCHEDULING, continued                                                  Policy #

Scheduling Self Pay Patients.................................................................................................... 380

Partnership Health Referrals.................................................................................................... 383

Scheduling Medicaid Patients.................................................................................................. 385

Call Policy.................................................................................................................................... 390

Physician Scheduling ................................................................................................................ 393

Scheduling for Physician Assistants (PAs)............................................................................. 395

 

CHAPTER 4:  REGISTRATION

Patient Account Assignment.................................................................................................... 405

New Patient Registration.......................................................................................................... 410

PSR Check-in……………………………………………………………………………………411

New Patient Check-in................................................................................................................ 415

Established Patient Check-in.................................................................................................... 420

Patient Check-out....................................................................................................................... 425

Satellite Clinics........................................................................................................................... 430

Treatment of Minors.................................................................................................................. 435

Self Pay Patients and Collecting Co-payments see Policy 380 under Appointment Scheduling

Workers’ Compensation Patients............................................................................................ 455

Mail Sorting................................................................................................................................. 460

Retrieving Faxes......................................................................................................................... 462

Alert Notes.................................................................................................................................. 470

Reception Department Orientation and Training................................................................. 495

 

CHAPTER 5:  PATIENT COMMUNICATION

Telephone Greeting Standards................................................................................................. 505

Telephone Communications..................................................................................................... 510

Patient Account Inquiries......................................................................................................... 530

Written Account Inquiries........................................................................................................ 540

Answering Service Transfer..................................................................................................... 550

Response to Patient Concerns.................................................................................................. 560

Patient Discharge....................................................................................................................... 570

Patient Missed Appointments “No Shows”........................................................................... 580

Patient Surveys........................................................................................................................... 590

 

CHAPTER 6:  MEDICAL RECORDS/TRANSCRIPTION

Medical Chart............................................................................................................................. 605

Storage and Retrieval of Medical Records............................................................................. 610

Chart Information Organization.............................................................................................. 615

Authorization to Release........................................................................................................... 620

Restriction for Use & Disclosure of PHI................................................................................. 621

Faxing Records from the Electronic Medical Records………………………………………623

Signature Log.............................................................................................................................. 625

Copying of Patient Records...................................................................................................... 630

Confidentiality............................................................................................................................ 635

Dictation...................................................................................................................................... 640

Purging........................................................................................................................................ 645

 

 

 

CHAPTER 6:  MEDICAL RECORDS/TRANSCRIPTION, continued                                Policy #

Destruction of PHI..................................................................................................................... 646

Subpoena Compliance............................................................................................................... 650

Subpoena Duces Tecum............................................................................................................ 655

Court Orders............................................................................................................................... 660

Search Warrant........................................................................................................................... 665

Medical Records Department Orientation and Training..................................................... 679

Transcription Procedures.......................................................................................................... 680

Transcription Notes Format..................................................................................................... 685

Saving/Printing Documents.................................................................................................... 686

Medical Spell check.................................................................................................................... 687

Using WinScribe and VPN....................................................................................................... 695

Transcription Department Orientation and Training........................................................... 699

 

CHAPTER 7:  PATIENT CLINICAL CARE / URGENT CARE

On Call vs. Town Call  --- see Policy 370 under Appointment Scheduling

Patient Clinical In-take.............................................................................................................. 705

Medical Emergencies................................................................................................................. 710

Return to Work-Medical Status Report Form........................................................................ 715

Back Office On-call..................................................................................................................... 720

Physician Call Trade Notification............................................................................................ 730

Home Health Certification Forms........................................................................................... 750

Minor Procedures in the Procedure Room............................................................................. 755

PRP Injections............................................................................................................................. 756

Ordering and Performing EKGs………………………………………………………………757

Scheduling {YOUR  PRACTICE} Surgeries in Centricity..................................................... 760

Urgent Care Physician Assistant Coverage........................................................................... 770

Urgent Care Physician Coverage............................................................................................. 780

Urgent Care Protocols --- see Policy 375 under Appointment Scheduling

Orthopedic Assistants Working from Home......................................................................... 790

Treatment and/or Service at Facilities Outside of {YOUR  PRACTICE} Employment... 793

Back Office Orientation and Training..................................................................................... 795

Sports Physical Screenings…………………………………………………………………….796

 

 

CHAPTER 8:  BENEFITS/PRE-AUTHORIZATIONS

Benefit Eligibility........................................................................................................................ 800

Surgical Estimates...................................................................................................................... 820

MRI Estimates............................................................................................................................. 830

Workers’ Compensation Authorization................................................................................. 840

Pre-Authorizations for Referrals to Outside Faciliities…………………………………….850

 

CHAPTER 9:  MEDICATION MANAGEMENT

Medication Management.......................................................................................................... 900

Safe Injection Practices.............................................................................................................. 905

Tetanus Shot Documentation………………………………………………………………….906

Pharmaceutical Representatives/Visitors.............................................................................. 910

Sample Medications................................................................................................................... 915

Dental Prophylaxis Protocols................................................................................................... 920

EPI Injection for Allergic Emergencies................................................................................... 921

 

 

CHAPTER 10:  ANCILLARY TEST REPORTING

Test Result Follow-up............................................................................................................... 1005

Initialing Test Results............................................................................................................... 1010

 

CHAPTER 11:  X-RAY

X-Ray Safety and General Policies.......................................................................................... 1105

STAT Read for X-rays............................................................................................................... 1106

Transferring Patients-Unable to Perform Exam................................................................... 1107

X-ray Staffing............................................................................................................................. 1110

X-ray Storage and Retrieval..................................................................................................... 1115

USB Drive for Use in Surgery.................................................................................................. 1117

X-Ray Image Tracking................................................................................................................ 1120

Digitizing Protocol.................................................................................................................... 1125

Deleting X-ray Images from DR Machine............................................................................. 1127

E-mailing Images from Office PACS...................................................................................... 1130

Charging for CDs...................................................................................................................... 1135

X-Rays for Outside Physicians................................................................................................ 1140

X-ray Informed Consent for Pregnant or Potentially Pregnant Patients.......................... 1141

Ordering X-rays for {YOUR  PRACTICE} Employees…………… ………………………1142

X-Ray Department Orientation and Training....................................................................... 1195

 

CHAPTER 12:  DURABLE MEDICAL EQUIPMENT (DME)

Overall DME Policies................................................................................................................ 1205

DME Collections........................................................................................................................ 1210

DME Given at Schools…………………………………………………………………………1215

DME Department Orientation and Training........................................................................ 1295

 

CHAPTER 13:  RISK MANAGEMENT AND QUALITY IMPROVEMENT

Process Improvement and Utilization Management........................................................... 1305

Accuracy and Completeness of Charges............................................................................... 1310

Accident/Incident Investigation Report............................................................................... 1320

Safety and Health Rules........................................................................................................... 1325

Record Retention....................................................................................................................... 1330

Emergency Action Plan-Office Invasion or Threat (Code Silver Policy).......................... 1333

Incident/Emergency Alert Notification................................................................................ 1335

Disaster Plan……………………………………………………………………………………1336

Treating Prison Inmates........................................................................................................... 1340

Student Internships and Job Shadowing............................................................................... 1345

 

CHAPTER 14:  INFORMATION SYSTEMS

Data Back-up Procedures......................................................................................................... 1405

Month-end Closing................................................................................................................... 1410

Year-end Closing....................................................................................................................... 1415

Outlook Email Signatures…………………………………………………………………….1420

Information Help Desk............................................................................................................. 1430

Disaster Management............................................................................................................... 1435

Security Level Designations.................................................................................................... 1445

Electronic Communication...................................................................................................... 1450

Copyright and Legal Issues..................................................................................................... 1455

Internet Security........................................................................................................................ 1465

Passwords................................................................................................................................... 1470

      CHAPTER 14:  INFORMATION SYSTEMS, continued                                                  Policy #

Workstations.............................................................................................................................. 1475

Information Security Agreement............................................................................................ 1480

Conference Phone Usage......................................................................................................... 1490

CPOE (Computerized Provider Order Entry)………………………………………………1495

 

 

CHAPTER 15:  FINANCIAL MANAGEMENT

Bank Reconciliation Process.................................................................................................... 1510

Check Signing............................................................................................................................ 1515

Charge Card Authorizations................................................................................................... 1520

Petty Cash Transactions........................................................................................................... 1530

Budget......................................................................................................................................... 1540

Month-end Closing................................................................................................................... 1545

Deposit of Patient Receipts...................................................................................................... 1550

Charitable Contributions.............................................................................................................. 1565

 

CHAPTER 16:  MATERIALS MANAGEMENT                                                                               

Purchasing Control................................................................................................................... 1605

Pricing Discounts...................................................................................................................... 1615

Group Purchasing..................................................................................................................... 1620

Maintenance/Leasing Contracts............................................................................................. 1625

Equipment and Service Requests............................................................................................ 1630

Terms for Borrowing Equipment  see Policy 225 under Personnel

Materials Management Department Orientation and Training......................................... 1695

 

CHAPTER 17:  COMPLIANCE

Exposure Control Plan............................................................................................................. 1705

Hazard Communication Program.......................................................................................... 1710

Hand Washing........................................................................................................................... 1715

Exam/Procedure Room Cleaning.......................................................................................... 1716

Universal Precautions............................................................................................................... 1720

Sharps and Needlestick............................................................................................................ 1725

Compliance................................................................................................................................ 1730

Risk Management...................................................................................................................... 1735

New Employee OSHA Orientation........................................................................................ 1740

 

CHAPTER 18:  FACILITIES

Fire Control and Evacuation................................................................................................... 1805

Secure Environment.................................................................................................................. 1810

Clean Environment................................................................................................................... 1815

Facility Cleaning Schedule....................................................................................................... 1825

Security Alarm........................................................................................................................... 1830

 

CHAPTER 19:  BILLING/ACCOUNTS RECEIVABLE

Superbill Form........................................................................................................................... 1900

Offsite Charges.......................................................................................................................... 1902

Coding........................................................................................................................................ 1904

CPC Certification and Conference Allowance...................................................................... 1905

Charge Entry.............................................................................................................................. 1906

Charging for Satellite Clinic Patients………………………………………………………..1907

Accurate and Timely Data Entry............................................................................................ 1908

CHAPTER 19:  BILLING/ACCOUNTS RECEIVABLE, continued                                      Policy #      

Charge and Appointment Reconciliation.............................................................................. 1910

Charge Correction..................................................................................................................... 1914

Billing Third Party Payers........................................................................................................ 1916

Private or Indemnity Carriers................................................................................................. 1918

Billing Secondary Insurance.................................................................................................... 1920

Billing Tertiary Insurance........................................................................................................ 1922

Claim Edits................................................................................................................................. 1924

Payment Posting........................................................................................................................ 1926

Payment Posting – Bank Deposit............................................................................................ 1928

Payment Posting – Interest Payments.................................................................................... 1930

Credit Card Payments.............................................................................................................. 1931

Credit Balances and Refunds.................................................................................................. 1932

Counterfeit Money…………………………………………………………………………… 1933

Claim Denials............................................................................................................................. 1934

Insurance Follow-up................................................................................................................. 1936

Patient Balance Follow-up....................................................................................................... 1938

Contractual Adjustments......................................................................................................... 1940

Patient Small Balances.............................................................................................................. 1942

Budget Plan................................................................................................................................ 1944

Collection Agency Policy......................................................................................................... 1946

Collection Account Payment................................................................................................... 1948

Alert Notes -- see Policy 470 under Registration

Bankruptcy................................................................................................................................. 1950

Financial Hardship................................................................................................................... 1952

Deceased Patients / Estates..................................................................................................... 1954

Workers’ Compensation.......................................................................................................... 1956

Bad Address............................................................................................................................... 1958

Non-sufficient Funds................................................................................................................ 1960

Collection Process..................................................................................................................... 1962

Collection Disputes................................................................................................................... 1964

Financial Policy......................................................................................................................... 1966

Fracture Care…………………………………………………………………………………...1967

Financial Arrangements for Surgery--- see Policy 820 under Benefits/Pre-Authorizations

Tribal Health Medicaid VA FRAF……………………………………………………………1971

Medicare Non-Covered Services – ABN............................................................................... 1972

Funds Transfer........................................................................................................................... 1974

Cash Discounts.......................................................................................................................... 1976

         Employee Discounts--- see Policy 245 under Personnel

Charges for Physicians and Family Members...................................................................... 1980

Charging for Miscellaneous Forms and JAs......................................................................... 1982

Depositions and IMEs.............................................................................................................. 1984

Minors of Divorced Parents..................................................................................................... 1986

Coding and Documenting Consults....................................................................................... 1988

Collecting Co-Payments and Full Pay Patients.................................................................... 1990

Incorrect/Incomplete Patient Demographics....................................................................... 1992

Maximum Medical Improvement (MMI).............................................................................. 1994

Tricare Policy…………………………………………………………………………………..1995

Patient Visits Split Between W-Comp. and Insurance........................................................ 1996

CHAPTER 19:  BILLING/ACCOUNTS RECEIVABLE, continued                                      Policy #

Patients Seeing Two Providers on the Same Day................................................................. 1997

Orientation and Training - Cashier........................................................................................ 1998

Orientation and Training – A/R……………………………………………………………..1999

 

CHAPTER 20:  SURGERY CENTER

Surgery Scheduling................................................................................................................... 2005

Financials Guidelines............................................................................................................... 2010

Budget Plan................................................................................................................................ 2011

Procedures Requiring an ABN Form..................................................................................... 2015

IV Antibiotic Charging............................................................................................................. 2020

Vendors....................................................................................................................................... 2080

Surgery Center Department Orientation Checklist............................................................. 2095

Sterling Select Patients………………………………………………………………………...2096

 

CHAPTER 21:  PHYSICAL THERAPY

Sports Medicine Outreach Hours/Mileage........................................................................... 2100

ASTYM Certification................................................................................................................ 2103

Physical Therapy Appointment Scheduling......................................................................... 2105

Scheduling Co-treatment Appointments Between PT and Clinic..................................... 2106

New Patient Check-in............................................................................................................... 2107

Established Patient Check-In................................................................................................... 2108

New Patient Registration......................................................................................................... 2109

Benefit Eligibility....................................................................................................................... 2110

Collecting Co-payments........................................................................................................... 2111

PT Self-pay Patients.................................................................................................................. 2120

Patient Check-out...................................................................................................................... 2121

Follow-up Appointments......................................................................................................... 2122

Cancellations.............................................................................................................................. 2124

Appointment No-Shows and Short-term Cancellations..................................................... 2125

Charge Entry.............................................................................................................................. 2130

Workers Compensation Authorizations................................................................................ 2132

Patient Safety Precautions for Clinic Treatments................................................................. 2140

Record Documentation............................................................................................................ 2141

PT Low Census.......................................................................................................................... 2190

Physical Therapy Staffing........................................................................................................ 2191

 

CHAPTER 22:  MRI

Prescribing Valium for MRI Patients..................................................................................... 2246   

MR Arthrogram Protocol......................................................................................................... 2247

Extravasation Policy................................................................................................................. 2248

MRI Contrast.............................................................................................................................. 2249

Scheduling MRIs....................................................................................................................... 2256

MRI No Show Policy................................................................................................................ 2257

MRI Staffing Protocol............................................................................................................... 2258

{PRACTICE} MR Environment Zoning................................................................................. 2270

MRI Employee Training Policy............................................................................................... 2271

Patient and Personnel Safety................................................................................................... 2272

MR Infection Control................................................................................................................ 2273

MRI Acute Medical Emergencies........................................................................................... 2274

CHAPTER 22:  MRI, continued                                                                                                   Policy #

MRI Pediatric Safety................................................................................................................. 2275

MR Education, Training and screening................................................................................. 2276

MR Environment Safety Policy............................................................................................... 2277

Accident-Incident MRI............................................................................................................. 2278

Equipment and Room Cleaning Policy.................................................................................. 2279

Correlation Policy..................................................................................................................... 2280

Management of Patient Reports.............................................................................................. 2281

Primary Source Verification Policy........................................................................................ 2285

MRI Orientation and Training……………………………………………………………….2290