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EHR Final

Electronic Health Records

QuestionAnswer
Treatment that is provided without admission to a hospital in settings such as physician practices, hospital emergency rooms, and clinics for outpatients is called ambulatory care
The order of the steps involved with health care claim processing is creating, transmitting, payer payment decisions, and payment posting
A compliance plan is a __________for finding, correcting, and preventing illegal medical office practices. process
The process of autoposting is handled by practice management programs
HITECH adds to the number of types of organizations that are considered____________, so that these overall organizations are now subject to HIPAA Privacy and Security rules. business associates
The provision of medical services at a less than acceptable level of professional skill that results in injury or harm to a patient is known as medical malpractice
The __________ is the standard for the identification of providers when filing claims and other transactions. NPI
Under HITECH, vendors hosting or using PHRs must notify ________and the Federal Trade Commission (FTC) of any breach caused by their products and services. patients
Common threats to information security include malware, natural disasters, and utility failures.
Which section of an electronic health record contains the outcome of all diagnostic procedures for a patient? laboratory tests and results
To protect consumers’ health, __________ governments pass laws that affect the medical services offered to patients. federal and state
An annual physical examination is an example of preventive care
__________ acknowledge(s) that an individual has mastered a standard body of knowledge and meets certain competencies. certification
When funds are sent directly to a practice's bank account, the transaction is known as electronic funds transfer (EFT)
Under HIPAA, the standard code set (until Oct. 1, 2013) for diseases is the ICD-9-CM
There are __________ components that must be included in a breach notification. five
The security standards contain requirements for what type of safeguards to prevent security breaches? technical, administrative, and physical (TAP)
Meaningful use is the utilization of certified EHR technology in the health care system to improve quality, improve efficiency, improve patient safety
A data warehouse is a collection of data that includes _______areas of an organization’s operations. all
What type of software program is widely used today to schedule patients’ appointments in the medical office? practice management program
Uses of clinical information, in addition to the primary use, such as for public health and homeland security, are referred to as secondary uses
The HIPAA Electronic Health Care Transactions and Code Sets (TCS) standards apply to electronic formats, code sets, and identifiers
The Institute of Medicine suggested that an EHR should include __________ core functions. three eight
Covering risk analysis results, audit reports, and security incident threat reports, _________ is a primary requirement for demonstrating HIPAA compliance. documentation
Patients own the content of their medical records, but the physicians who created the record _________the physical documents. own
Dr. Goldman kept an electronic file of Jane Hellman’s visits with him for all her encounters to treat her hand fracture; she has been released to physical therapy. Choose the category for this record. EMR
One advantage of PM programs is that Physicians receive payment in less time because they send electronic claims.
What type of information about the business is entered in a PM? provider data, transaction data, and patient data
The federal False Claims Act makes it illegal to submit a _______ claim. fraudulent
A _________ code is used to represent for a patient’s Alzheimer’s disease. diagnosis code
A claim for William J. Lopez has been rejected by a health plan. The health plan states that the procedure code is for a Cesarean delivery. What is the likely problem? mismatch between a female-only service and the fact that the patient is male
Patient medical records are legal documents
The integrated practice management program and electronic health record used in the text/workbook is Medisoft Clinical
The data standard for transmitting HIPAA transactions has been ASC X12 4010. What will the standard be on January 1, 2012? ASC X12 5010
There is an unwritten law of medical insurance, if a procedure is not ___________, then in the view of the payer, it was not done and should not be billed. documented
Enforcing civil violations of HIPAA privacy and security rules is the job of OCR
Most HIPAA privacy complaints are settled by voluntary compliance
In the health care field, a commitment to ____________ is a key component of success. lifelong learning
Covered entities and their _____________ are responsible for determining whether a breach has occurred to which the notification obligations apply. business associates
The purpose of EHRs is to replace paper records
A medical record may have the physician's assessment, diagnosis, and treatment plan.the patient’s medical historyand results of laboratory work
Examples of HIPAA standard transactions are electronic claims, health plan payments, and health plan eligibility inquires/responses
The diagnosis and procedures in the patient’s medical record should be logically connected, so that the __________ of the charges is clear to the health plan. medical necessity
Under the HITECH Act, HIPAA’s Privacy and Security Rules now extend directly to BAs
Under the HIPAA Electronic Health Care Transactions and Code Sets standards, CEs must use __________ electronic formats for health care transactions and the same code sets for diagnoses, procedures, and supplies. the same specified
Under HIPAA, a __________ is a group of codes used for encoding data elements. code set
For the greatest career opportunities for advancement in health technology, new employees need computer skill, knowledge of health care reform, and health care skill
The HIPAA Privacy Rule provides protection for individually identifiable health information and grants certain rights to ______in regard to their medical records. individuals
What is the meeting of a patient with a physician or other medical professional for the purpose of providing health care? encounter
Created by: CUAHIT