Chapter 4 insurance
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| Written or graphic information about patient care is termed a | Health record
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| ________ is written or dictated to record chronologic facts and observations about a patient's health | Documentation
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| 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
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| 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
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| a list of all staff members' names, job titles, signatures, and their initials is know as | signiture log
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| 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
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| name six documentation components of a patients history | cheif complaint, history of present illness, review of systems, past history, family history, social history
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| an inventory of body systems by documenting responses to questions about symptoms that a patient has experienced is called a | review of systems
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| 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
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| 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
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| 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
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| referral | is the transfer of the total or specific care of a patient from one physician to another for know problems
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| 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
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| 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
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| 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
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| If a fax machine is misdirected, either ___________ or ______________ | telephone; complete a msdirected fax form online and fax it to the original number
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| how long to keep computerized payroll records | 7 years
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| how long to keep insurance claim for Medicare patient | 7 years
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| how long to keep medical record of a deceased patient | 5 years
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| How long to keep active patient medical records | indefinite retention
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| how long to keep telephone records | indefinite retention
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| 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
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| can a physican terminate a contract with a patient | yes, by sending a letter of withdrawl registered or certified with return signature card
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| renders service to a patient | treating or performing physician
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| directs selection, preparation, and administration of tests, medication, or treatment | Ordering physican
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| Legally responsible for the care and treatment given to a patient | attending physican
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| gives an opinion regarding specific problem that is requested by another doctor | consulting physician
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| sends the patient for tests or treatment or to another doctor for consultation | referring physician
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| oversees care of patients in managed care plans and refers patients to see specialists when needed | primary care physician
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| responsible for training and supervising medical students | teaching physician
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| clinical nurse specialist or licensed social worker who treats a patient for a specific medical problem and uses the results | non-physician practitioner
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| performs one or more years of training in a specialty area while working at a hospital (medical center) | resident physician
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| 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
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| the SOAP style of documentation that a physician uses to chart a patients progress in the health record means | subjective, objective, assessment, and plan
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| a physical examination of a patient performed by a physican is | objective
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| 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
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| when there is an underlying disease or other conditions are present at the time of the patients office visit, this is termed | comorbidity
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| a patients hospital discharge summary contains the discharge diagnosis but not the admitting diagnosis | false
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| an eponym should not be used when a comparable anatomic term can be used in its place | true
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| 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
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| 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
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| assigned insurance claims for Medicaid and Medicare cases must be kept for a period of 7 years | true
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| pertaining to both sides | bilateral
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| act of cutting out | excision
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| condition that runs a short but severe course | acute
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| localized or in one specific location | in situ
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| through the skin | percutaneous
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| condition persisting over a long period of time | chronic
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| RLQ | right lower quadrant
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| DC | discharge
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| WNL | within normal limits
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| R/O | rule out
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| URI | upper respitory infection
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| _ c | with
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| + with a circle around it | positive
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| when documenting incisions, the unit of measure length be listed in | centimeters (cm)
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| 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
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| if a physician asks you to locate the results of the last UA, what would you be searching for | a urinalysis report
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| 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
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| 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
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| when documenting incisions, the unit of measure length be listed in | centimeters (cm)
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| 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
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| 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
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| if a physician asks you to locate the results of the last UA, what would you be searching for | a urinalysis report
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| if a physician asks you to locate the results of the last UA, what would you be searching for | a urinalysis report
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| 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
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| 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
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| if you were asked to make a photocopy of the patients last CT, what would you be searching for | computed tomograghy scan
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| if you were asked to make a photocopy of the patients last CT, what would you be searching for | computed tomograghy scan
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Created by:
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