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EHR Exam 7
| Term | Definition |
|---|---|
| Which of the following contains codes for certain products, supplies and services that do not appear in the CPT manual? | HCPCS |
| Codes that identify the procedures performed for a patient are called: | CPT |
| The first three factors a coder must consider when coding are patient status, place of service and : | Type of service |
| The anesthesia section in the E/M codes is used for the following types of anesthesia: local, regional and: | General anesthesia |
| Providers who have not adopted an EHR system by 2014 are subject to: | Financial penalties |
| What is a legal doctrine which holds that medical services rendered must be reasonable and necessary to generally accepted clinical standards? | Medical Necessity |
| Which of the following CPT conventions indicates the code descriptions is revised? | Blue Triangle |
| Multigravida is a term associated with: | Pregnancy |
| A log that contains information about the prescription order and is used to document the administration of the medication to the patient is: | Medication administration Record |
| What is essential for proper E/M Code assignment | Documentation |
| Electronic Health Record (EHR) | Computerized lifelong health care record w/ data from all sources technology that intertwines health info from a variety of sources every encounter an individual has w/ the health care system is documented (labs, scripts, ER visits, etc...) |
| New position created by EHR | Clinical Analyst, Health Information Technician, Records and Information Coordinator |
| What setting may a Certified Electronic Health Records Specialist (CEHRS) work in? | Dr. Office labs, Ref Labs, Urgent Care Centers, Nursing Home Facilities, Wellness Clinics, Hospitals |
| Why were changes in technology made? | Electronic Medical Records failure to meet the needs of dr's & pt's, increases in errors, rising health care costs, and missing link in a pt's coordination of care. |
| Medical Errors | -Among most common causes of death, occur b/c: *Lost medical records *Miscommunicated pt request/messages *Unreadable info due to poor handwriting *Mislabeled lab specimens |
| What potential does HIT have? | improve the quality of care and possibly reduce the number of deaths attributed to medical errors |
| What was HIPPA designed for? | enacted in 1996, designed to protect pt's private health info, ensure health care coverage when workers change or lose their jobs, and uncover fraud and abuse in health care systems. |
| True or False: HIPPA requires the use of electronic rather than paper ins claims? | True |
| Standards | commonly agreed upon specifications, are what helped establish the requirements necessary for agencies to follow |
| When did Pres Bush recommend the use of Health Information Technology (HIT)? What was the goal? Who was established to meet this goal? | In 2004, set 10 yr goal for all americans to be using EHR's, and established the OFFICE OF NATIONAL COORDINATION FOR HEALTH INFORMATION (ONCHIT) to meet this goal. |
| HITSP | department/organ that identified standards for exchange of health info |
| CCHIT | developed certification criteria for EHR software |
| What does the Nationwide Health Information Network (NHIN) provide? | links medical records across the country |
| What 8 core functions does the Institute of Medicine suggest an EHR should include? | 1) Health Info and data elements 2) Results Management 3) Order Management 4) Decision Support 5) Electronic communications and connectivity 6) Patient Support 7) Administrative Processes 8) Reporting and population management |
| Medical Record | an important business document used to support treatment decisions documents services provided could also be used in court of law for evidence purposes |
| Electronic Medical Record (EMR) | computerized records of one dr's encounter w/ a pt over time including medical history, diagnosis, treatment and prognosis |
| What is the contrast between EMR's and EHR's? | EMR's reflect treatment of a pt by one dr as EHR reflects data from ALL sources that have treated and ind |
| Personal Health Record (PHR) | maintained & owned by the pt, pt makes decisions whether to share contents w/ their dr. |
| Acute Care | most often refers to a hospital, treats pt's w/ urgent problems that cannot be handled in another setting (hospital records keep track of time-limited episodes where dr charts reflect the ongoing health of ind) **Inpatient treatment** |
| Ambulatory Care | refers to treatment w/o admission to hospital |
| What are the advantages of EHR's? | Safety Quality of Care Efficiency Cost Reduction |
| Will the decision of going completely electronic have a huge impact on pt efficiency? | Yes |
| Total Conversion | method of converting medical records all at one from paper to electronic, may be costly, but it allows all pt data to be converted at once while office can still service pt's **outsourced to an external company** |
| What is Incremental Conversion? | gradual change to electronic records. Advantage: lower cost and a smoother transition due to less of an impact on the office. Disadvantages: paper still needs to be used & not all pt data is available. **usually begins w/ pt's w/ scheduled appt*** |
| What is Hybrid Conversion? | using a combination of paper and electron form of data. No matter what form is used dr still need to enter progress notes (most dr choose dictation/transcription process) **some may be outsourced, others in house* |
| What are clinical templates and what do they allow? | structured form (progress notes) allow dr's to document pt encounters on an EHR, once it is entered it must be INTEROPERABLE: must be able to exchange info & use it in a meaningful way, therefore clinical standards are important to the details of pt info |
| Clinical Standards | -ensure consistency, reliability and safety |
| Types of Clinical Standards | CLINICAL VOCABULARIES, SNOMED-CT, LOINC, UMLS |
| CLINICAL VOCABULARIES | set of common definitions for medical terms, they ease communications by decreasing ambiguity |
| SNOMED-CT | clinical vocabulary designed to encompass all terms used in medicine |
| LOINC | terms and codes used for electronic exchange of lab results and clinical observations |
| UMLS | thesaurus database of medical terms |
| What are CLASSIFICATION SYSTEMS? | they organize terms into categories for easy retrieval, they are used for billing and reimbursement, statistical reporting and admin functions |
| ICD-9 and ICD-10 | International Classification of Disease-standard developed by World Health Organization (WHO) contains diagnosis codes that are used in all health care settings. |
| ICD-9-CM | DIAGNOSIS USAGE: Inpatient & Outpatient *Number of characters: 3-5 alphanumeric *Number of Codes: 13,000 PROCEDURE USAGE: Inpatient* *# of characters: 3-4 numeric *# of codes 4,000 |
| ICD-10-CM | DIAGNOSIS USAGE: inpatient & outpatient *# of characters: 3-7 alphanumeric *# of codes: 120,00 PROCEDURE USAGE: none |
| ICD-10-PCS | DIAGNOSIS USAGE: none PROCEDURE USAGE: inpatient *# of characters: 7 alphanumeric *# of codes: 200,000 |
| CPT | Current Procedural Terminology- list of descriptive terms and identifying codes for reporting medical services and procedures performed by health care professionals in outpatient setting, developed and maintained by American Medical Association (AMA) |
| CPT Code Ranges | EVALUATION & MANAGEMENT (E&M): 99201-99499 ANESTHESIA: 00100-01999 KO begin w/ 0 SURGERY: 10021-69990 want to feel 100% begin w/ 1 RADIOLOGY: RPM, R=7 begin w/ 7 PATH & LAB: 80047-89356 RPM. P=8 begin w/ 8 MEDICINE: 90281-99607 RPM, M=9 begin w/ 9 |
| HCPCS | Healthcare Common Procedure Coding System- level II, national codes, contains codes for products, supplies, and certain services not included in CPT. Codes are maintained by Center for Medicare and Medicaid Services (CMS) |
Created by:
jr84