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MOA 160

EHR Test 3

QuestionAnswer
Why should blocks of time be moved from the medical office schedule? no longer needed
What does out the door mean? To get the patient discharged and out the door asap
What does diagnosis mean? what is wrong with the patient/the reason why they came to the doctor
What does ICD stand for? International Classification of Diseases
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
What are safeguards and why are they needed? they protect patient's PHI, lets CE access PHI, used to not interfere with computer access
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
Why is the Clinic Status Screen in EHR helpful for the office team? So everybody can see it and know what's going on
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
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
What is the act of converting a diagnosis to a numeric or alpha-numeric value? coding
What is the current version of ICD in the US? ICD-9-CM
Who provides and maintains ICD codes? WHO- World Health Organization
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
What are the 3 components for determining level of service? History, Physical, Medical Decision Making
What is required for code determination? the 3 key components
What is the term when a physician refers a patient to a specialist? Consultation
What are the components from least to most complex? 1)Problem Focused 2)Detailed Oriented 3)Comprehensive
What is used to substantiate procedure and diagnostic code selections for proper reimbursements? documentation
What is the routine practice that unusual billing patterns alert insurance companies to perform? Audits
What should office managers perform weekly to determine if any unauthorized information was accessed? Audit Trails
What is the difference between authorization and consent? Authorization- in writing permission Consent- verbal permission
Who is the office that submits claims electronically and they are known under HIPAA? Covered Entities
What is confidentiality? keeps PHI secret
What is the proper name of the procedure coding handbook? Current Procedural Terminology
How often are the coding books updated? Once a year
What is the list of acceptable charges for medical procedures? fee schedule
What are the locations that a consultation can take place? doctor's office, hospital, nursing home
What organization addresses portability of insurance coverage? HIPAA
What type of legal document is an electronic medical report? permanent
What is the minimum necessary rule? It applies to the amount of information that is requested
How does unethical behavior relate to the law? Sometimes it can be punished by the law and sometimes it cannot
Who can be the privacy officer in a medical office? Office Manager
What is overcoding? coding for something more to get an increased payment
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
What is important to know about faxing medical records? Discouraged to do so, but can do it, If faxing, must fax with a disclaimer
Created by: nyanis
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