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insurance chapter 4
Chapter 4 insurance
| Question | Answer |
|---|---|
| Written or graphic information about patient care is termed a | Health record |
| ________ is written or dictated to record chronologic facts and observations about a patient's health | Documentation |
| Performance of service or procedures consistent with the diagnosis, done with standards of good medical practice and a proper level of care given in the appropriate setting is known as | medical necessity |
| If a medical practice is audited by Medicare officials and intentional miscoding is discovered, _____________ may be levied and providers may be ______________ | penalties, escluded from the program |
| a list of all staff members' names, job titles, signatures, and their initials is know as | signiture log |
| how should an insurance billing specialist correct an error on a patient's record | use legal copy pen cross out wrong enty with a single line, write the correct enty, date, initial entry. Never erase or use white-out or self adhesive paper over error |
| name six documentation components of a patients history | cheif complaint, history of present illness, review of systems, past history, family history, social history |
| an inventory of body systems by documenting responses to questions about symptoms that a patient has experienced is called a | review of systems |
| new patient is | one who has not recieved any professional services from the physician or another physician of the same specialty who belongs to the same practice, within the past 3 years |
| established patient is | one who has recieved professional services from the physician or another physician of the same practice who belongs to the same practice, within the past 3 years |
| consultation is | includes services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patients illness or a suspected problem |
| referral | is the transfer of the total or specific care of a patient from one physician to another for know problems |
| if two physicians see the same patient on the same day, one for the patients heart condition and the other for a diabetic situation, this medical care situation is called | concurrent care |
| medical care for a patient who has recieved treatment for an illness and is referred to a second physician for treatment of the same condition is a situation called | Continuity of care |
| a patients protected health information may be disclosed for treatment, payment, or health care operations, but for other situations, and especially when faxing a patients medical records, a signed document for_________________________ must be obtained. | authorizing release of information via the fax machine |
| If a fax machine is misdirected, either ___________ or ______________ | telephone; complete a msdirected fax form online and fax it to the original number |
| how long to keep computerized payroll records | 7 years |
| how long to keep insurance claim for Medicare patient | 7 years |
| how long to keep medical record of a deceased patient | 5 years |
| How long to keep active patient medical records | indefinite retention |
| how long to keep telephone records | indefinite retention |
| is the proper insurance billing specialist to recieve a subpoena for his or her physician | yes, if the physician gives him or her this authority |
| can a physican terminate a contract with a patient | yes, by sending a letter of withdrawl registered or certified with return signature card |
| renders service to a patient | treating or performing physician |
| directs selection, preparation, and administration of tests, medication, or treatment | Ordering physican |
| Legally responsible for the care and treatment given to a patient | attending physican |
| gives an opinion regarding specific problem that is requested by another doctor | consulting physician |
| sends the patient for tests or treatment or to another doctor for consultation | referring physician |
| oversees care of patients in managed care plans and refers patients to see specialists when needed | primary care physician |
| responsible for training and supervising medical students | teaching physician |
| clinical nurse specialist or licensed social worker who treats a patient for a specific medical problem and uses the results | non-physician practitioner |
| performs one or more years of training in a specialty area while working at a hospital (medical center) | resident physician |
| During the performance of an external audit to review a medical practices health records, the system used to show deficiencies in documentation is called | point system |
| the SOAP style of documentation that a physician uses to chart a patients progress in the health record means | subjective, objective, assessment, and plan |
| a physical examination of a patient performed by a physican is | objective |
| a health care management process after doing a history and physical examination on a patient that result in a plan of treatment is called | medical decision making |
| when there is an underlying disease or other conditions are present at the time of the patients office visit, this is termed | comorbidity |
| a patients hospital discharge summary contains the discharge diagnosis but not the admitting diagnosis | false |
| an eponym should not be used when a comparable anatomic term can be used in its place | true |
| if the phrase "rule out" appears in a patients health record in connection with a disease, then code the condition as if it exited | false |
| during a prospective review or prebilling audit, all procedures or services and diagnoses listed on the encounter form must match the data on the insurance claim form | true |
| assigned insurance claims for Medicaid and Medicare cases must be kept for a period of 7 years | true |
| pertaining to both sides | bilateral |
| act of cutting out | excision |
| condition that runs a short but severe course | acute |
| localized or in one specific location | in situ |
| through the skin | percutaneous |
| condition persisting over a long period of time | chronic |
| RLQ | right lower quadrant |
| DC | discharge |
| WNL | within normal limits |
| R/O | rule out |
| URI | upper respitory infection |
| _ c | with |
| + with a circle around it | positive |
| when documenting incisions, the unit of measure length be listed in | centimeters (cm) |
| if a physician called and asked for a patients medical record STAT, what would he or she mean | the physician wants the record delievered immediately |
| if a physician asks you to locate the results of the last UA, what would you be searching for | a urinalysis report |
| if a physician telephoned and asked for a copy of the last H&P to be faxed, what is being requested | a history and physicial |
| if a hospital nurse telephoned and asked you to read the results on the patients last CBC, what would you be searching for | complete blood count |
| when documenting incisions, the unit of measure length be listed in | centimeters (cm) |
| if a physician called and asked for a patients medical record STAT, what would he or she mean | the physician wants the record delievered immediately |
| if a physician called and asked for a patients medical record STAT, what would he or she mean | the physician wants the record delievered immediately |
| if a physician asks you to locate the results of the last UA, what would you be searching for | a urinalysis report |
| if a physician asks you to locate the results of the last UA, what would you be searching for | a urinalysis report |
| if a physician telephoned and asked for a copy of the last H&P to be faxed, what is being requested | a history and physicial |
| if a hospital nurse telephoned and asked you to read the results on the patients last CBC, what would you be searching for | complete blood count |
| if you were asked to make a photocopy of the patients last CT, what would you be searching for | computed tomograghy scan |
| if you were asked to make a photocopy of the patients last CT, what would you be searching for | computed tomograghy scan |
Created by:
Lea99