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EHR Exam 6
| Term | Definition |
|---|---|
| What is the most common encounter with patients in an ambulatory setting? | Office visit |
| An ONC meaningful use criteria mandates that a certified EHR program must be able to record the patient's? | Height, weight, blood pressure, BMI |
| PMHX is an abbreviation for the: | Patient's Past Medical History |
| The format for Level II codes in the HCPCS is a letter followed by ___ numbers. | Four |
| The ICD-10-CM is comprised of which of the following? | Diagnoses |
| The best definition for structured progress notes that the physicians use to document patient encounters in an EHR is: | Clinical templates |
| Which of the following is not a safety screening performed by the e-prescribing module within the EHR? | Drug-Tolerance |
| The ICD-10-PCS includes procedure codes for which of the following: | Procedures codes for the patient |
| Most individuals receiving TANF payments are limited to a ______________ year benefit period. | 5 |
| The format for the ICD-10-PCS is: | A 7 digit code with a combination of numbers and letters |
| What is the proper action to take when a very ill patient enters the office? | Assist the patients into the examination room in order for them to wait comfortable until the physician is ready to see them. |
| When working under a managed care plan, physicians agree to: | Accept fees that are predetermined by the plan. |
| A lab report cannot be used for coding purposes because: | They are not reviewed by a physician before inclusion in the record. |
| The HCPCS codes are maintained by which of the following? | The Centers for Medicare and Medicaid Services |
| Consultation letters are different from referral letters. They are different because: | A consultation is when a doctor request the opinion or advice from another doctor. |
| In documenting patient history, the letters PFSH stands for: | Past history, family history and social history |
| Who should be billed for the treatment of an emancipated minor? | The Minor |
| What is a private, secure electronic file that is created, maintained and owned by the patient called? | Personal Health Record |
| Patient safety and reducing medical errors is extremely important in adopting an EHR system. What could be considered a contributing factor to medical errors? | Illegible or incorrectly interpreted handwritten orders |
| Often Doctor's do not have the expertise to treat a specific patient's condition. The doctor will send the patient to a board certified doctor for treatment. This is call a/an: | Referral |
| Medical Identify Theft is a type of fraud. In this type of theft, a person's personal identify details are stolen. Examples of person details include a social security number and which of the following: | Health Insurance ID |
| When you report a procedure in addition to the primary procedure, this term is known as: | Add-on codes |
| The lettes "qhs" means: | At each bedtime |
| What is the abbreviation for a patient's expressed concern? | c/o |
| When is the secondary insurance plan billed? | After payment for the primary is received |
| the three key factors in selecting an E/M code are: | history, examination and medical decision making |
| _________________ are used to report encounters for circumstances other than a disease or injury in ICD-10 CM. | Z codes |
| The amount of that an insurance company may say is not allowed and not the responsibility of the patient, for a contracted physician, would be identified as this on the patient's account | An adjustment |
| The UB-04 is used to submit: | hospital claims |
| If a patient is admitted to the hospital 4 times in one year, how many times will they be entered in the Master Patient index? | Four |
| Information such as policyholder name and insurance plan appear in the _________ section of a claim form. | Subscriber |
| What type of findings includes information the care provider gathers from performing a physical exam? | Assessment |
| What type of findings is the patient's description of his/her symptoms? | Subjective |
| A list of all medical procedures and their respective allowed amounts for any insurance company is known as: | Fee Schedule |
| Software that is used in a medical office is known as: | Practice management software |
| How many times is a patient entered into the Patient List or Master Patient Index | Every time they are seen for a visit |
| What identifying information, that differentiates one patient from another, is collected as part of the administrative information? | Demographics |
| Physicians establish a list of their usual fees for: | The procedures and services they frequently perform |
| What do the letters NOS indicate? | Equals unspecified |
| The common abbreviation for chest x-ray is: | CXR |
| If a fracture is not documented as closed or open, it is always coded as: | Closed |
| What is meant by "code to the highest level of specificity"? | using the most specific code possible |
| A code that reports more than one diagnoses with one code is a ____________________ code. | Combination |
| The biggest advantage of voice recognition software over manual transcription is: | Speed of documentation |
| There must be a _____________ to perform any test of treatments: | Order by the care provider |
| The use of ePrescribing is part of the requirement for: | HIPAA |
| Notes about a prescription ordered for a patient would appear in the _________________ of a SOAP note. | Plan |
| On a prescription, the "SIG" is which part of the prescription? | The instructions on taking the medicine. |
| Who manages a personal health record (PHR)? | The individual |
| In using an EHR, the word "cloning" refers to: | Copying and pasting notes from the patient's previous visits into the current progress note. |
Created by:
jr84