A physician correctly prescribes warfarin. The patient takes the warfarin as prescribed but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case?
Hematuria; adverse reaction to warfarin
What system assigns each service a value representing the true resources involved in producing it, including the time and intensity of work, the expenses of practice, and the risk of malpractice?
RVUs
A notation for a hypertensive patient in a physician ambulatory care progress note reads: “Blood pressure adequately controlled.” In which part of a problem oriented medical record (POMR) progress note would this notation be written?
Assessment
Online transaction processing is conducted in which of the following?
Clinical data repository
The Information Governance Principles for Healthcare (IGPHC) includes the statement that, “An organization shall maintain its information for an appropriate time, taking into account its legal, regulatory, fiscal, operational, risk, and historical require
Principle of retention
The NCCI editing system used in processing OPPS claims is part of which of the following?
Outpatient code editor (OCE)
A coding audit shows that an outpatient coding professional is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following shou
Counsel the coding professional and stop the practice immediately.
Which of the following is considered the most innocent of improper payments because there is no intent to falsely receive a payment from the payer?
Error
Which of the following is used by computer-assisted coding software to translate digital text from online documents stored in the information system into codes to match the documentation?
Natural-language processing
The privacy officer reports breaches to the Office of Civil Rights in the Department of Health and Human Services. Which of the following breach notification statements is correct?
The privacy officer must notify the Secretary of Health and Human Services.
