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study guide
Fordney 4, Kinn's 9
| Question | Answer |
|---|---|
| During an audit, when are points awarded? | If documentation is present for elements required in a health record. pg. 96 Fordney. |
| When can private insurance carriers claim refunds? | When services did not occur, or were not completed. |
| What is the difference between a refferal and a consultation? | Consultation includes services rendered by a physician whose opinion/advice is requested, referral is the transfer of total or specific care to another physician for a known problem. pg. 105 |
| What is an Eponym? | The name of a disease, structure, operation or procedure derived by the name of a place, or person whom discovered it. pg 107 Fordney. |
| what is the difference between chronic condition and reccurant condition? | Chronic condition last for a long period of time, where a recurrent condition comes and goes. pg. 107 Fordney. |
| Define edit check? | An audit prevention measure, used to check for errors or conflicting in coding. pg. 113 Fordney. |
| Who is able to accept a supeona in a doctor's office? | The physician or the authorized keeper of the health records. pg. 116-117 Fordney. |
| What is the key to substanciating appropriate procedures and diagnostic code selection? | Supporting documentation in the health record. pg.124 Fordney |
| What does S.O.A.P. stand for? | Subjective, Objective, Assessment, Plan. pg. 95 Fordney |
| Where should we make documentation when a patient fails to return for a needed treatment? | In the patient's health record. pg 119 Fordney |
| How do we correct errors in the electronic medical record? | Key over the incorrect entry, substitute correct information, date & electronically initial the entry. pg. |
| What is the difference between prospective review & retrospective review? | Prospective and review is before the billing insurance carrier, and retrospective review is after insurance carrier. pg. 112 Fordney |
| Define audits? | If a provider has submitted insurance claims for payments that are deemed to be fraudulent or inappropriate by the government, then an investigaton may be conducted in the form of an audit of the practice's finacial record. pg. 96 Fordney |
| Define query? | Request for information from a database. Kinn's glossary |
| Define "within normal limits"? | Commonly used phrases or abbreviations that may not support billing of services are "WNL" (within normal limits) pg. 107 Fordney |
| Define abstract? | To compile an outline or summary for use in procedural coding. Kinn's glossary |
| Define location, as it pertains to E & M? | Area of the body where the symptom is occuring. pg 96 Fordney |
| Define quality? | Character of the symptom/pain (burning, gnawing, stabbing, fullness) pg.96 Fordney |
| Define serverity? | Degree of symptom or pain on a scale of 1- 10 (Severity also can be described with terms such as severe, slight, and persistant.) pg. 96 Fordney |
| Define duration? | How long the symptom/pain has been present, and how long it lasts when the patient has it. pg. 96 Fordney |
| Define timing? | When the pain/symptom occurs (for example morning evening, and after or before meals) pg. 96 Fordney |
| Define context? | The situation associated with the pain/symptom. pg. 96 Fordney |
| Define modifying factors? | Things or actions that occur to make the symptom/pain worse or better. pg. 96 Fordney |
| Define associated signs & symptoms? | Things that happen when the illness occurs. pg.96 Fordney |
| What are three way a physician may withdrawl from care of a non-compliant patient? | Send letter of withdrawal to the patient with return receipt by certified mail, send discharge confirmation w/receipt, statement signed that patient left the physician,signed statement by patient in health record, pg. 119-120 Fordney. |
| When should an Eponm be used? | When there is no comparable medical term. pg. 107 Kinn's. |
| What is "subjective"? | Statement of symptoms & complaints in the patient's own words.pg. 95 Fordney |
| What is "objective"? | Findings. pg 95 Fordney. |
| What is "assessment"? | Subjective & objective findings. pg. 95 Fordney. |
| What is "plan"? | The plan of action to take, for treatment. pg. 95 Fordney. |
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