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Rvwr exam 2 MEDA 160
| Question | Answer |
|---|---|
| The key to substantiating procedure and diagnostic code selections for appropriate reimbursement is a supporting electronic health record. | false (supporting documentation in EHR) |
| Physicians are required to use the documentation guidelines developed by the AMA and CMS, formerly the HCFA. | False |
| Private insurance carriers have the right to claim refunds in the event of accidental miscoding. | True |
| A problem-focused examination is more complex than a detailed examination. | False |
| An established patient is anyone who has previously received professional services from the physician or another physician of the same specialty who belongs to the group practice. | True |
| A consultation may take place in a home, office, hospital, or extended care facility. | True |
| A referral is the same as a consultation. | False |
| When the physician provides critical care in the hospital emergency department, it is billed as emergency care. | True |
| An eponym should not be used when a comparable anatomic term can be used in its place. | True |
| The word chronic should be used instead of recurrent for a medical condition that persists over a long period. | False |
| Skin repairs are coded according to the sum of the length of the repairs in centimeters. | True |
| During an external audit, points are awarded when documentation is present. | True |
| An audit program is composed of policies and procedures to accomplish uniformity, consistency, and conformity in medical record keeping that fulfills official requirements. | False |
| An edit check is a good audit prevention measure to have in place. | True |
| The American Health Information Management Association approves the use of the fax machine in all routine transmissions of patient information. | False |
| A patient’s financial data should never be faxed. | True |
| The acceptance of a subpoena by an authorized person is the equivalent of a subpoena being served personally. | True |
| When each entry in the medical record is worded similar to the previous entries, this is considered | cloned documentation |
| An electronic medical report is a | permanent legal document and part of the health record |
| The key to substantiating procedure and diagnostic code selections for proper reimbursement is | supporting documentation in the electronic health record |
| The chronologic recording of pertinent facts and observations about the patient’s health is known as | documentation |
| Reasons for documentation are | defense of a professional liability claim, insurance carriers require accurate documentation that supports procedure and diagnostic codes |
| The SOAP in patient medical record charting may be defined as | subjective, objective, assesment plan |
| When a patient fails to return for needed treatment, documentation should be made | medical record, app book, financial record, card ledger |
| How should an entry in a patient’s electronic medical record be corrected? | note that a section is in error,enter the correct information when and why the physician changed the entry, electronic sig, date and time |
| A concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter is abbreviated as | chief complaint |
| Levels of evaluation and management services are based on type(s) of physical examination that may be | problem-focused |
| An expanded problem-focused examination is a/an | limited exam of the affected body area |
| The official American Hospital Association policy states that “abbreviations should be totally eliminated from the more vital sections of the record, such as the” | final diagnosis, operative notes, & discharge summaries, and descriptions of special procedures |
| A diseased condition or state is known as | morbidity |
| What does comorbidity mean? | Underlying disease or other conditions present at the time of the visit |
| A new patient is one who | has not received any professional service with the physician witing the past 3 years |
| An established patient is one who | has previously received professional service from a physician or another physician of the same specialty who belongs to the group practice within the past 3 years |
| In dealing with managed care plans, a referral is | the transfer or the total or specific care of a patient from one phyician to another and the term used when requesting an authorization for the patient to receive services elsewhere BOTH B AND C |
| Your physician has been to the hospital providing constant bedside attention and treating a patient in respiratory failure. These services are considered | define critical care |
| When a discussion takes place with a patient concerning the risks and benefits of treatment options, it is considered | counseling |
| Parts of the small and large intestines, right ovary, right uterine tube, appendix, and right ureter are found in the | right lower quadrant |
| Repair of lacerations that require layered closure of one or more of the deeper layers of the skin and tissues is known as | intermediate |
| The code for repair of a superficial laceration is found in the CPT Integumentary/Surgery section under the heading | simple |
| A review of patient records done before billing is submitted is called | prospective |
| Once an individual has been found guilty of committing a Medicare or Medicaid program–related crime, | exclusion from program participation is mandatory |
| Which of the following cases should NOT use fax transmission? | Transmission of documents relating to information on sexually transmitted diseases. Any routine transmission of patient information. Transmission of documents relating to alcohol treatment |
| Who may accept a subpoena? | The prospective witness, or an authorized person |
| Preservation of health records is governed by | state and local law |
| Records that must be retained indefinitely include | patients' medical records, x-ray films, and inactive patients' medical records |
| It is the responsibility of the ____________________ to handwrite or dictate the documentation for medical transcription. | physician provider |
| If a professional liability claim is filed by a patient, good ____________________ helps establish a strong defense. | documentation |
| Criteria used by insurance companies when making decisions to limit or deny payment in which medical services or procedures must be justified by the patient’s symptoms and diagnosis are called ____________________. | medical necessity |
| Most insurance companies perform routine ____________________ on practices with unusual billing patterns or excessive payment amounts. | audits |
| A reference list of all staff members’ names, job titles, signatures, and their initials is known as a/an ____________________. | signature log |
| An inventory of body systems obtained through a series of questions that are used to identify signs and/or symptoms of the patient is known as a/an ____________________. | review system |
| The documentation of the patient’s previous experiences with illnesses, operations, injuries, and treatments is known as the ____________________. | past history |
| Review of medical events in the patient’s family, including diseases that may be hereditary, is known as a/an ____________________. | family history |
| Age-appropriate review of past and current activities of the patient (e.g., smoking or use of alcohol) is known as a/an ____________________. | social history |
| The abbreviation CC stands for ____________________. | chief complaint |
| The abbreviation HPI stands for ______________________________. | history of present illness |
| The abbreviation ROS stands for _________________________. | review of systems |
| The abbreviation PH stands for ____________________. | past history of illnesses, operations, injuries, treatments |
| The abbreviation FH stands for ____________________. | family history |
| The abbreviation SH stands for ____________________. | social history |
| A statement describing symptoms and problems as a reason for the office visit is known as the patient’s ____________________. | chief complaint |
| A disease that runs a short but relatively severe course is referred to as ____________________. | acute |
| The term ____________________ refers to a disease that persists over a long time. | chronic |
| When documenting a case for billing, a level must be determined from one of ____________________ types of medical decision making. | four [[4 types are 1. straightforward (SF), 2. low complexity (LC), 3. moderate complexity (MC), 4. high complexity (HC)]] |
| When a patient receives similar services by more than one physician on the same day, it is called ____________________ care. | concurrent |
| PFSH is the abbreviation for ___________________________________. | past, family, and social history (PFSH) |
| WNL is the abbreviation for _________________________. | within normal limit |
| The upper middle region above the stomach is known as the ____________________ region. | epigastric region |
| An internal review known as ______________________________ is done after billing insurance carriers. | retrospective review |
| To determine whether there is a lack of documentation, the insurance billing specialist may be asked to perform a/an ______________________________. | retrospective review |
| To prevent deterioration, fax transmissions received on ____________________ paper should be photocopied onto regular paper before they are put into the medical record. | fax |
| Provider who sends the patient for tests or treatment.\ | referring physician |
| Provider whose opinion is requested by another physician about evaluation and management of a specific problem. | consulting physician |
| Provider who is the medical staff member legally responsible for the care and treatment given to a patient. | attending physician |
| Individual who directs the selection, preparation, or administration of tests, medications, or treatment. | ordering physician |
| Provider who renders a service to a patient. | treating or performing physician |
| Situation associated with the pain/symptom | context |
| Area of the body in which the symptom is occurring | location |
| When the pain/symptom occurs | timing |
| Character of the symptom/pain (burning, gnawing) | quality |
| How long the symptom/pain has been present and how long it lasts when the patient has it | duration |
| Symptom/pain and other changes that are noted when the symptom/pain occurs | associated signs and symptom |
| Degree of symptom and/or pain on a scale from 1 to 10 | severity |
| Things done to make the symptom/pain worse or better | modifying factors |
| Services rendered by a physician whose opinion is requested by another physician for evaluating a patient’s illness | consultation |
| Transfer of the total care of a patient from one physician to another | referral |
| Providing similar services to the same patient by more than one physician on the same day | concurrent care |
| Providing treatment for a patient and subsequent referral by the treating physician to another physician for treatment of the same condition | continuity of care |
| Discussion with a patient, family, or both about diagnostic results and instructions for treatment | counseling |
| Intensive care provided during an acute life-threatening condition that requires constant bedside attention by the physician | critical care |
| Care provided during a life-threatening condition in the hospital emergency department | emergency |
Created by:
FB