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MOA 160
EHR Test 3
| Question | Answer |
|---|---|
| Why should blocks of time be moved from the medical office schedule? | no longer needed |
| What does out the door mean? | To get the patient discharged and out the door asap |
| What does diagnosis mean? | what is wrong with the patient/the reason why they came to the doctor |
| What does ICD stand for? | International Classification of Diseases |
| Why are aftercare instructions important? | It informs the patient as to what they can and can't do, how to take any prescriptions, when to return to the facility if needed |
| What are safeguards and why are they needed? | they protect patient's PHI, lets CE access PHI, used to not interfere with computer access |
| What does the phrase, "if it was not documented, it did not happen' mean? | documenting health records provides evidence that visits and any procedures occurred, if it's not documented, it looks like nothing happened and therefore, the clinical staff cannot get paid |
| Why is the Clinic Status Screen in EHR helpful for the office team? | So everybody can see it and know what's going on |
| What is subjective, objective, assessment and plan? | SOAP- patient complaint, what doctor finds to be true about patient complaint, how he goes about to find the truth, what he does to fix it |
| What will a physician do if the patient's problem is beyond his or her scope of abilities? | refer the patient to a specialist that can treat the problem |
| What is the act of converting a diagnosis to a numeric or alpha-numeric value? | coding |
| What is the current version of ICD in the US? | ICD-9-CM |
| Who provides and maintains ICD codes? | WHO- World Health Organization |
| What types of codes and what section of the book that you find these codes that professional services of face to face time are charged with? | E/M of the CPT Book |
| What are the 3 components for determining level of service? | History, Physical, Medical Decision Making |
| What is required for code determination? | the 3 key components |
| What is the term when a physician refers a patient to a specialist? | Consultation |
| What are the components from least to most complex? | 1)Problem Focused 2)Detailed Oriented 3)Comprehensive |
| What is used to substantiate procedure and diagnostic code selections for proper reimbursements? | documentation |
| What is the routine practice that unusual billing patterns alert insurance companies to perform? | Audits |
| What should office managers perform weekly to determine if any unauthorized information was accessed? | Audit Trails |
| What is the difference between authorization and consent? | Authorization- in writing permission Consent- verbal permission |
| Who is the office that submits claims electronically and they are known under HIPAA? | Covered Entities |
| What is confidentiality? | keeps PHI secret |
| What is the proper name of the procedure coding handbook? | Current Procedural Terminology |
| How often are the coding books updated? | Once a year |
| What is the list of acceptable charges for medical procedures? | fee schedule |
| What are the locations that a consultation can take place? | doctor's office, hospital, nursing home |
| What organization addresses portability of insurance coverage? | HIPAA |
| What type of legal document is an electronic medical report? | permanent |
| What is the minimum necessary rule? | It applies to the amount of information that is requested |
| How does unethical behavior relate to the law? | Sometimes it can be punished by the law and sometimes it cannot |
| Who can be the privacy officer in a medical office? | Office Manager |
| What is overcoding? | coding for something more to get an increased payment |
| What is the difference between referral and consultation? | Referral- sending a patient to another doctor for complete care about a certain condition Consultation- getting a second opinion on a patient's condition |
| What is important to know about faxing medical records? | Discouraged to do so, but can do it, If faxing, must fax with a disclaimer |
Created by:
nyanis
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