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insurance chapter 4

Chapter 4 insurance

QuestionAnswer
Written or graphic information about patient care is termed a Health record
________ is written or dictated to record chronologic facts and observations about a patient's health Documentation
Performance of service or procedures consistent with the diagnosis, done with standards of good medical practice and a proper level of care given in the appropriate setting is known as medical necessity
If a medical practice is audited by Medicare officials and intentional miscoding is discovered, _____________ may be levied and providers may be ______________ penalties, escluded from the program
a list of all staff members' names, job titles, signatures, and their initials is know as signiture log
how should an insurance billing specialist correct an error on a patient's record use legal copy pen cross out wrong enty with a single line, write the correct enty, date, initial entry. Never erase or use white-out or self adhesive paper over error
name six documentation components of a patients history cheif complaint, history of present illness, review of systems, past history, family history, social history
an inventory of body systems by documenting responses to questions about symptoms that a patient has experienced is called a review of systems
new patient is one who has not recieved any professional services from the physician or another physician of the same specialty who belongs to the same practice, within the past 3 years
established patient is one who has recieved professional services from the physician or another physician of the same practice who belongs to the same practice, within the past 3 years
consultation is includes services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patients illness or a suspected problem
referral is the transfer of the total or specific care of a patient from one physician to another for know problems
if two physicians see the same patient on the same day, one for the patients heart condition and the other for a diabetic situation, this medical care situation is called concurrent care
medical care for a patient who has recieved treatment for an illness and is referred to a second physician for treatment of the same condition is a situation called Continuity of care
a patients protected health information may be disclosed for treatment, payment, or health care operations, but for other situations, and especially when faxing a patients medical records, a signed document for_________________________ must be obtained. authorizing release of information via the fax machine
If a fax machine is misdirected, either ___________ or ______________ telephone; complete a msdirected fax form online and fax it to the original number
how long to keep computerized payroll records 7 years
how long to keep insurance claim for Medicare patient 7 years
how long to keep medical record of a deceased patient 5 years
How long to keep active patient medical records indefinite retention
how long to keep telephone records indefinite retention
is the proper insurance billing specialist to recieve a subpoena for his or her physician yes, if the physician gives him or her this authority
can a physican terminate a contract with a patient yes, by sending a letter of withdrawl registered or certified with return signature card
renders service to a patient treating or performing physician
directs selection, preparation, and administration of tests, medication, or treatment Ordering physican
Legally responsible for the care and treatment given to a patient attending physican
gives an opinion regarding specific problem that is requested by another doctor consulting physician
sends the patient for tests or treatment or to another doctor for consultation referring physician
oversees care of patients in managed care plans and refers patients to see specialists when needed primary care physician
responsible for training and supervising medical students teaching physician
clinical nurse specialist or licensed social worker who treats a patient for a specific medical problem and uses the results non-physician practitioner
performs one or more years of training in a specialty area while working at a hospital (medical center) resident physician
During the performance of an external audit to review a medical practices health records, the system used to show deficiencies in documentation is called point system
the SOAP style of documentation that a physician uses to chart a patients progress in the health record means subjective, objective, assessment, and plan
a physical examination of a patient performed by a physican is objective
a health care management process after doing a history and physical examination on a patient that result in a plan of treatment is called medical decision making
when there is an underlying disease or other conditions are present at the time of the patients office visit, this is termed comorbidity
a patients hospital discharge summary contains the discharge diagnosis but not the admitting diagnosis false
an eponym should not be used when a comparable anatomic term can be used in its place true
if the phrase "rule out" appears in a patients health record in connection with a disease, then code the condition as if it exited false
during a prospective review or prebilling audit, all procedures or services and diagnoses listed on the encounter form must match the data on the insurance claim form true
assigned insurance claims for Medicaid and Medicare cases must be kept for a period of 7 years true
pertaining to both sides bilateral
act of cutting out excision
condition that runs a short but severe course acute
localized or in one specific location in situ
through the skin percutaneous
condition persisting over a long period of time chronic
RLQ right lower quadrant
DC discharge
WNL within normal limits
R/O rule out
URI upper respitory infection
_ c with
+ with a circle around it positive
when documenting incisions, the unit of measure length be listed in centimeters (cm)
if a physician called and asked for a patients medical record STAT, what would he or she mean the physician wants the record delievered immediately
if a physician asks you to locate the results of the last UA, what would you be searching for a urinalysis report
if a physician telephoned and asked for a copy of the last H&P to be faxed, what is being requested a history and physicial
if a hospital nurse telephoned and asked you to read the results on the patients last CBC, what would you be searching for complete blood count
when documenting incisions, the unit of measure length be listed in centimeters (cm)
if a physician called and asked for a patients medical record STAT, what would he or she mean the physician wants the record delievered immediately
if a physician called and asked for a patients medical record STAT, what would he or she mean the physician wants the record delievered immediately
if a physician asks you to locate the results of the last UA, what would you be searching for a urinalysis report
if a physician asks you to locate the results of the last UA, what would you be searching for a urinalysis report
if a physician telephoned and asked for a copy of the last H&P to be faxed, what is being requested a history and physicial
if a hospital nurse telephoned and asked you to read the results on the patients last CBC, what would you be searching for complete blood count
if you were asked to make a photocopy of the patients last CT, what would you be searching for computed tomograghy scan
if you were asked to make a photocopy of the patients last CT, what would you be searching for computed tomograghy scan
Created by: Lea99 on 2012-03-01



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