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MJCC EHR
Electronic Health Record
| Question | Answer |
|---|---|
| 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 medical 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 |
| An element of the user interface on which the user can click to execute a command such as confirm, cancel or exit? | Button |
| For whatever reason, what must be documented in the patient's medical record. | Making corrections in/on the appointment schedule |
| An EHR Specialist will call the insurance company prior to? | Scheduling hospital services and admissions. |
| The EHR specialist must ensure that each part of the___________ is accurate, and up to date. | medical records |
| Employers that pay directly for 'employees' medical bills | Health Insurance Terminology, Self ensured |
| Family members covered by parents insurance plan are called | Dependents |
| The actual charge less/minus the allowed amount. | Approved/Allowed Amount |
| Providers/Physicians who agree to accept an insurance allowed amount as payment in full. | Participating/Preferred Providers |
| A condition named for a person-such as Hodgkin's disease. | Eponym |
| Conditions that remain after a patient's acute illness or injury has ended - could be called residual effects or late effects. | Sequelae |
| Physicians, hospitals and other suppliers that furnish care or supplies to patients are called? | Providers |
| A beneficiary pays what? | deductible, premiums, co-insurance (20%) non-covered services |
| Medicare pays | Covered services 80% |
| EHRC Specialist job duties | Submitting insurance claim forms, patient check in and check out, insurance verification, scheduling appointments. |
| Information that is essential for an EHR Specialist to collect at the time of an appointment. | Correct spelling of patient's full name, address, telephone number, reason for visit, type of insurance, |
Created by:
PRO Teacher
Healthtrade
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