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Fordney 4, Kinn's 9

QuestionAnswer
During an audit, when are points awarded? If documentation is present for elements required in a health record. pg. 96 Fordney.
When can private insurance carriers claim refunds? When services did not occur, or were not completed.
What is the difference between a refferal and a consultation? Consultation includes services rendered by a physician whose opinion/advice is requested, referral is the transfer of total or specific care to another physician for a known problem. pg. 105
What is an Eponym? The name of a disease, structure, operation or procedure derived by the name of a place, or person whom discovered it. pg 107 Fordney.
what is the difference between chronic condition and reccurant condition? Chronic condition last for a long period of time, where a recurrent condition comes and goes. pg. 107 Fordney.
Define edit check? An audit prevention measure, used to check for errors or conflicting in coding. pg. 113 Fordney.
Who is able to accept a supeona in a doctor's office? The physician or the authorized keeper of the health records. pg. 116-117 Fordney.
What is the key to substanciating appropriate procedures and diagnostic code selection? Supporting documentation in the health record. pg.124 Fordney
What does S.O.A.P. stand for? Subjective, Objective, Assessment, Plan. pg. 95 Fordney
Where should we make documentation when a patient fails to return for a needed treatment? In the patient's health record. pg 119 Fordney
How do we correct errors in the electronic medical record? Key over the incorrect entry, substitute correct information, date & electronically initial the entry. pg.
What is the difference between prospective review & retrospective review? Prospective and review is before the billing insurance carrier, and retrospective review is after insurance carrier. pg. 112 Fordney
Define audits? If a provider has submitted insurance claims for payments that are deemed to be fraudulent or inappropriate by the government, then an investigaton may be conducted in the form of an audit of the practice's finacial record. pg. 96 Fordney
Define query? Request for information from a database. Kinn's glossary
Define "within normal limits"? Commonly used phrases or abbreviations that may not support billing of services are "WNL" (within normal limits) pg. 107 Fordney
Define abstract? To compile an outline or summary for use in procedural coding. Kinn's glossary
Define location, as it pertains to E & M? Area of the body where the symptom is occuring. pg 96 Fordney
Define quality? Character of the symptom/pain (burning, gnawing, stabbing, fullness) pg.96 Fordney
Define serverity? Degree of symptom or pain on a scale of 1- 10 (Severity also can be described with terms such as severe, slight, and persistant.) pg. 96 Fordney
Define duration? How long the symptom/pain has been present, and how long it lasts when the patient has it. pg. 96 Fordney
Define timing? When the pain/symptom occurs (for example morning evening, and after or before meals) pg. 96 Fordney
Define context? The situation associated with the pain/symptom. pg. 96 Fordney
Define modifying factors? Things or actions that occur to make the symptom/pain worse or better. pg. 96 Fordney
Define associated signs & symptoms? Things that happen when the illness occurs. pg.96 Fordney
What are three way a physician may withdrawl from care of a non-compliant patient? Send letter of withdrawal to the patient with return receipt by certified mail, send discharge confirmation w/receipt, statement signed that patient left the physician,signed statement by patient in health record, pg. 119-120 Fordney.
When should an Eponm be used? When there is no comparable medical term. pg. 107 Kinn's.
What is "subjective"? Statement of symptoms & complaints in the patient's own words.pg. 95 Fordney
What is "objective"? Findings. pg 95 Fordney.
What is "assessment"? Subjective & objective findings. pg. 95 Fordney.
What is "plan"? The plan of action to take, for treatment. pg. 95 Fordney.
Created by: MAAs_rock