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Electronic Health Record

When thinking of an Electronic Health Record, EHR, the word audit means? A review of employee activity with in the EHR system
An EHR function that allows a doctor or another prescriber to order medication and tests using an automated format is called a? Computerized Physician Order Entry (CPOE)
The ability of separate EHR systems to share information in compatible formats is called? Interoperability
If both parents cover dependents on their plan, the child's primary insurance is usually determined by the birthday rule. What is the birthday rule? The parent whose birthday is earlier in the calendar year
An active patient is defined as? One who saw the provider within the last 3 years
Codes that identify common types of patient visits, specify their typical duration and identify special instructions to handling each kind of visit, are called? Type of Visit Code (TOV)
When you electronically archive patient records, where do they go? To archive media such as a CD or a hard drive
Why should closed patient records be purged and placed in electronic storage? Liability reasons in the event of medical malpractice.
What is the purpose of a billing audit? To identify poor coding
Lack of documentation during a patient visit could result in? Decreased reimbursement
A reference database (thesaurus) of medical terms? UMLS
Claire works for a pediatrician's office that is considering the implementation of an EHR. She has been asked to research the different systems available and would like to create a list of functions the EHR should have specific to their practice she needs to get ____________________________? doctor recommendations
If a patient has had a malignancy removed and no further treatment is needed it is coded as: History
The best definition for a company that processes health information and executes electronic transactions is: Clearinghouse
What term is unique to ICD-10-CM and indicates that the condition being excluded is not part of the condition for the code listed but rather another code should also be assigned: Excludes
How is payment received in and electronic office? An electronic deposit is made into an online office account where money can then be transferred as needed.
Evaluation and Management Codes (E/M Codes) are based on three factors: history, physical examination and: Evidence of medical decision making
The process of moving a patient from appointment making through checkout is called? Patient flow
According to the flow of information what comes next: appointment scheduling, front desk/check in, nursing clinical support, __________________. Care Provider
______________________ is easily attained when using an EHR system. Interoperability
Data may be structured or unstructured. Identify an example of unstructured data. Dictated Report
Used by physicians to access information about a disease or condition. Decision Support Software
Health Level 7 (HL7) standards allow what: Allows different software to interface with each other
Using a __________________ will ensure each member of the staff has defined the data element correctly. Data Dictionary
This type of technology translates what a provider is saying and types those words into text. Voice Recognition
The acronym HIE stands for: Health Information Exchange
Which acronym was one of the first terms used in the idea of storing medical information electronically? EHR
The primary care physician for some types of managed care plans is also referred to as the? The Gatekeeper
The process of entering fees for services on a patient account is referred to as? Posting payments
A patient with Medicare is working at a small business with fewer than 15 employees. She also has a group plan with this employer. Which insurance is primary for medical services? Employer Group plan
If a patient is injured in an automobile accident, what type of insurance is applicable? Liability Insurance
What type of insurance covers employees that are injured on the job? Worker's compensation
Only services deemed medically ________________ can be billed to insurance. Necessary
To help guard against security breaches, emails containing protected health information should be? Encrypted
Currently, participation in the Physician Quality Reporting Initiative is ____________. Voluntary
Procedures and any accompanying template text are automatically added into what area of the SOAP note when saved? Assessment
For a specialist to document in a rapid and efficient way, many EHR companies provide what? Pre-built office visits, physicians order and letter templates for each specialty.
A well integrated electronic healthcare system should be able to: transmit, store, receive and ___________ all medical services related to a patient's healthcare. Protect
What type of statement needs to appear on a (fax cover sheet) when transmitting Personal Health Information? Confidentiality statement
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? Patient's Past Medical History
The format for Level II codes in the HCPCS is a letter followed by how many numbers? Four
The ICD-10-CM is comprised of only what? Diagnoses
What allows doctors to document patient encounters in an EHR system on a structured form? 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 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 patient into the examination room 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 have not been reviewed by a physician before inclusion into the record.
The HCPCS codes are maintained by? The Centers for Medicare and Medicaid Services
Consultation letters are different from referral letters because, a consultation letter 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 which is called a? Referral
Medical Identity theft is a type of fraud where a person's personal identity details are stolen. Examples of these details could include a social security number and a _________________ ? Health Insurance ID
When you report a procedure in addition to the primary procedure, this term is known as? Add-on codes
The letters "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 from the primary insurance 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 the ICD-10 CM? Z codes
The amount an insurance company may say is not allowed and not the responsibility of the patient would be identified as an ___________________ on the patient's account? Adjustment
A 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? Once
Information such as policyholder name and insurance plan appear in what section of a claim form? Subscriber
A list of all medical procedures and their respective allowed amounts charged by 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? Only once, which allows for documentation of each 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? Not Otherwise Specified or 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 is a ____________________ code? Combination
The biggest advantage of voice recognition software over manual transcription is? Speed of documentation
There must be an ____________ by the care provider, before any tests or treatment can be provided to a patient? Order
The use of the ePrescribing module is part of the requirement for? Hipaa
Notes about prescriptions ordered for a patient would appear in what section of the SOAP note? Plan
On a prescription order, the "SIG" is what 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 a patient's previous visits into the current progress notes.
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 Codes
The first three factors a coder must consider when coding are patient status, place and _______________ ? Type of service
The anesthesia section in the E/M codes is used for the following types of anesthesia: local, regional and _____________ anesthesia? general
Providers who had not adopted an EHR system by 2014 were subject to? Financial penalties
What is the legal doctrine, that states that all medial services rendered must be reasonable and necessary to generally accepted clinical standards? Medical Necessity
A CPT code that indicates the code description has been revised? Blue Triangle
Multigravida is a term associated with? Pregnancy
A log that contains information about a prescription order and is used to document the administration of the medication to the patient is? Medication administration Record
What is essential to proper E/M Code assignment? Documentation
Computerized records of (one physician's) encounter with a patient over time and reflects treatment of that one physician? Electronic Medical Records (EMR)
Reflects data from (all sources) that have treated an individual? Electronic Health Record (EHR)
Registration, Admissions, Discharge and Transfer acronym? RADT
A unique patient identifier acronym, that links all clinical observations, tests, procedures, complaints, evaluations, and diagnoses to the patient? UPI
A dictated report, a written progress note, or voice files are what kind of data? Unstructured data
Standard templates, bar codes and numeric codes are what kind of data? Structured data
The length of time records are stored by a medical office is called? Retention Time
Indicates a patient's behavior or current status? Status Code
Codes that identify common types of patient visits, specify their typical duration and identify special instructions to handling each kind of visit? Type of Visit Code
Rules that require the usage of password protection on all electronic devices used to access patient information? HIPAA Security Rules
Identifiers are a unique set of numbers (like SSN's) used in electronic transactions for Employers, Healthcare Providers, Health Plans and Patients and are called? HIPAA National Identifiers
A generated term used to help the user (specific context) to carry out a particular task is called? Context Specific
Other systems designed to interact with Electronic Health Records, (EHR) and used for patient identification, orders, scheduling and testing/results? Laboratory, Pharmacy and Radiology Systems
A set of common definitions for medical terms that ease communication by decreasing uncertainty? Clinical vocabularies
Clinical vocabulary designed to encompass all terms used in medicine? SNOMED-CT
Terms and codes used for electronic exchange of lab results and clinical observations? LOINC
The method of (adding information) to the Electronic Health Record (EHR) is identified as? SOAP note charting
What type of information is the patient's description of his/her own symptoms, including a chief complaint, or comments during an exam? SUBJECTIVE information
What kind of information would it be where observations are made by a physician or EHR Specialist? OBJECTIVE information
What section of a SOAP note would there be a brief summary of the patient's symptoms and may often include a diagnosis as well as a list of other possible diagnoses, usually in order of 'most likely, to least likely? ASSESSMENT
Notes about a prescription ordered for a patient would appear in the __________ of a SOAP note? PLAN
Four types of information contained in a medical record? Personal, Financial, Medical and Social information.
A government program that provides insurance for persons over the age of 65? Medicare
Insurance for low income people? Medicaid
Insurance for (active duty) and (retired) service personnel and their families? TRICARE
Insurance for (Veteran's) with service related disabilities? CHAMPVA
When a policyholder contributes to his/her policy by paying a set amount of money on a Fee Schedule, is called their? Premium
The method of determining insurance payments must be? UCR-Usual, Customary and Reasonable
A set amount patients may be required to pay the provider for health care services before their benefits begin to pay is called a? Deductible
A set percent (%) of charges a patient may be required to pay according to the guidelines set forth by their insurance policy is called what? Co-insurance
What form is used to submit hospital claims? UB-04 form
Health Maintenance Organization acronym? HMO
Preferred Provider Organization acronym? PPO
Exclusive Provider Organization acronym? EPO
Point of Service acronym? POS
The ICD-9 have how many characters? 3-5 characters
The ICD-10 have how many characters? 3-7 characters
Not Elsewhere Classifiable acronym? NEC
Most often refers to (care in a hospital) where patients are treated with urgent problems, that cannot be handled otherwise is called? Acute care
What refers to treatment without admission to a hospital? Ambulatory Care
Where are patients listed and entered only once which allows for documentation of all office visits? Master Patient Index (MPI)
What is the method of scheduling a patient for a specific appointment time? Fixed appointment scheduling
What is the method of scheduling patients around the same block of time? Cluster scheduling
What method is scheduling two patients to see the same physician at the same time? Double booking
What method is it when patients are scheduled for the first half of each hour, and each patient is seen in the order they arrive? Wave scheduling
What part of the SOAP note is it added to when a care provider gathers information from performing a physical exam? Assessment
What is it called when offices charge fees based on a patient's financial ability? Sliding Fee Scale
Administrative data is unnecessary for? Providers
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