EHR Test 3
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Why should blocks of time be moved from the medical office schedule? | no longer needed
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| What does out the door mean? | To get the patient discharged and out the door asap
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| What does diagnosis mean? | what is wrong with the patient/the reason why they came to the doctor
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| What does ICD stand for? | International Classification of Diseases
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| Why are aftercare instructions important? | It informs the patient as to what they can and can't do, how to take any prescriptions, when to return to the facility if needed
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| What are safeguards and why are they needed? | they protect patient's PHI, lets CE access PHI, used to not interfere with computer access
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| What does the phrase, "if it was not documented, it did not happen' mean? | documenting health records provides evidence that visits and any procedures occurred, if it's not documented, it looks like nothing happened and therefore, the clinical staff cannot get paid
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| Why is the Clinic Status Screen in EHR helpful for the office team? | So everybody can see it and know what's going on
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| What is subjective, objective, assessment and plan? | SOAP- patient complaint, what doctor finds to be true about patient complaint, how he goes about to find the truth, what he does to fix it
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| What will a physician do if the patient's problem is beyond his or her scope of abilities? | refer the patient to a specialist that can treat the problem
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| What is the act of converting a diagnosis to a numeric or alpha-numeric value? | coding
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| What is the current version of ICD in the US? | ICD-9-CM
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| Who provides and maintains ICD codes? | WHO- World Health Organization
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| What types of codes and what section of the book that you find these codes that professional services of face to face time are charged with? | E/M of the CPT Book
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| What are the 3 components for determining level of service? | History, Physical, Medical Decision Making
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| What is required for code determination? | the 3 key components
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| What is the term when a physician refers a patient to a specialist? | Consultation
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| What are the components from least to most complex? | 1)Problem Focused
2)Detailed Oriented
3)Comprehensive
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| What is used to substantiate procedure and diagnostic code selections for proper reimbursements? | documentation
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| What is the routine practice that unusual billing patterns alert insurance companies to perform? | Audits
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| What should office managers perform weekly to determine if any unauthorized information was accessed? | Audit Trails
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| What is the difference between authorization and consent? | Authorization- in writing permission
Consent- verbal permission
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| Who is the office that submits claims electronically and they are known under HIPAA? | Covered Entities
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| What is confidentiality? | keeps PHI secret
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| What is the proper name of the procedure coding handbook? | Current Procedural Terminology
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| How often are the coding books updated? | Once a year
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| What is the list of acceptable charges for medical procedures? | fee schedule
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| What are the locations that a consultation can take place? | doctor's office, hospital, nursing home
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| What organization addresses portability of insurance coverage? | HIPAA
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| What type of legal document is an electronic medical report? | permanent
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| What is the minimum necessary rule? | It applies to the amount of information that is requested
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| How does unethical behavior relate to the law? | Sometimes it can be punished by the law and sometimes it cannot
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| Who can be the privacy officer in a medical office? | Office Manager
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| What is overcoding? | coding for something more to get an increased payment
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| What is the difference between referral and consultation? | Referral- sending a patient to another doctor for complete care about a certain condition
Consultation- getting a second opinion on a patient's condition
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| What is important to know about faxing medical records? | Discouraged to do so, but can do it, If faxing, must fax with a disclaimer
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