Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
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:
Healthtrade
Popular Medical sets