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Week 4 Study Guide

Week 4 Chapter 10 Study Guide

QuestionAnswer
an independent audit should be performed a minimum of twice a year
if documentation in the patient chart supports a higher level of service than that coded, the error would be called downcoding
when auditing a medical chart, the auditor should verify that all documentation is initialed or signed by the provider
if documentation in the patient chart supports a lower level of service than that coded, the error would be called upcoding
Key components for selecting evaluation and management (E/M) codes include all except Complexity of the diagnosis
if medicare determines that an evaluation and management (E/M) service exceeds the patients documented need medicare could deny payment
Types of Medical records audits include everything except certification audits
A prepayment audit would verify the data of service & the patients insurance identification number
A post payment would not verify the coders skill and knowledge
a postpayment audit would verify sign-in sheets & appointment scheduling practices
an internal audit can be conducted either prospectively or retrospectively
an internal prospective audit would most likely be performed on workers compensation claims
an internal audit would determine the coders skill & knowledge, whether procedures were coded correctly & if additional training is needed for office staff
What is a disadvantage of a prospective internal audit? it delays insurance payment
physician offices should audit their medical records to ensure compliance w/ HIPAA regulations, determine the accuracy of the physicians documentation & assess the completeness of the medical record.
Medical necessity of evaluation and management (E/M) services is based on all expect procedures performed to address the problem
the most widely used CPT codes are evaluation & management (E/M)
the most extensive type of history is comprehensive
documentation of a review of systems (ROS) is required in all types of histories except problem focused
Documentation of an extended history of present illness (HPI) includes at least four HPI elements
an expanded problem-focused history requires all elements except past, family, & social history (PFSH)
if a patient states that the pain he or she is experiencing is burning, the element he or she would be describing is the quality
if a patient states that present illness started 3 days ago, the element he or she would be describing is the duration
if a patient states that the pain he or she is experiencing is in the right arm, the element he or she would be describing is the location
if a patient complains of a dull ache in the left ear over the past 24 hours, he or she would be describing three HPI elements
history of present illness (HPI) types include brief or extended
what is a type of review of systems comprehensive
if a physician examines the system directly related to the problem plus two to nine additional systems, the review of systems would be considered extended
if a PFSH includes a review of the patients past, family, & social history, it would be considered complete
If a chart note documents that the patient is status post-thyroid resection 10 years ago, this would be an example of the patients past history
If a chart note documents that the patient has smoked two packs of cigarettes every day for the past 10 years, it would be an example of the patients social history
in documenting a medical examination, all are recognized organ systems except head, including face
in documenting a medical examination, all are recognized body areas except skin
an examination that involves one or more organ systems or body areas is called a general multi-system exam
In documentation of a medical exam, the terms musculoskeletal, respiratory, & gastrointestinal would refer to organ systems
If a physician documents that an exam included the measurement of a patients blood pressure, the system examined would be the cardiovascular system
An examination that documents a limited examination of the affected body area or organ system and any other symptomatic or related body areas would be considered a expanded problem-focused exam
A chart that reports an exam involving at least nine organ systems or body areas would be documentation of a(n) comprehensive exam
Elements of medical decision making include all of the following except number of procedures or services provided
In a patients chart, a diagnosis can be stated or implied
If a physician who ordered a test personally reviews the results to supplement information from the physician who prepared the test report, the work would add to the level of the amount and/or complexity of data to be reviewed
If the level of risk of motality is high, the medical decision making would be considered High
If a patient presents with one self-limited or minor problem, the level of risk involved with the medical decision making would be considered Minimal
If a patient presents with an acute or chronic illness that poses a threat to life or body fucntion and requires emergency surgery, the level of risk involved with the medical decision making would be considered High
The risk of significant complication, morbidity, and/or mortality is based on the risks of presenting problems, diagnostic procedures, & possible management options
To consider time as the key factor in determining the level of evaluation & management (E/M) services, the counseling and/or coordiantion of care must make up 50% of the encounter
A medical office specialist can find clinical examples for documenting medical necessity in the CPT Appendix C
If a medical office assistent is NOT sure about which evaluation & management (E/M) code to use he or she should ask for help
An example of an evaluation and management (E/M) code that requires three key components documented and a comprehensive history and comprehensive exam is a new patient office visit
Physician services that are more intense than the work of other evaluation and managements (E/M) services and that involve frequent personal assessment by the physician would be coded as critical care
Clearinghouses charge providers based on which type of payment system? A percentage of each claim's dollar value & a flat fee per claim
The type of ROS that inquires about the system directly related to the problem identified in the history of present illness (HPI) Problem-Pertinent Review of Systems
Software function used by payers to screen for incorrect or improperly reported procedure codes Code Edits
The type of audit conducted within a practice to make sure the office is compliant Internal Audit
The type of audit conducted by an insurance carrier to make sure a practice is compliant External Audit
The type of review of systems (ROS) that inquires about the system directly related to the problem identified in the history of present illness (HPI) plus all additional body systems Complete review of systems
The type of audit done before a claim is submitted to the insurance carrier for payment Prospective
The type of review of systems (ROS) that inquires about the system directly related to the problem identified in the history of present illness (HPI) and two to nine additional systems extended review of systems
the type of audit performed after payment is received from an insurance carrier retrospective
Created by: studee86