question

ARRA

answer

American Recovery and Reinvestment Act

question

C level of history or examination

answer

comprehensive [level of history or examination]

question

CC

answer

chief complaint

question

CCU

answer

coronary care unit

question

D level of history or examination

answer

detailed

question

dx/Dx

answer

diagnosis

question

ED/ER

answer

emergency department or emergency room

question

EHR

answer

electronic health record

question

E/M service

answer

evaluation and management

question

EMR

answer

electronic medical record

question

EPF level of history or examination

answer

expanded problem focused

question

ESI

answer

Electronically stored information

question

fax

answer

Facsimile

question

FH

answer

family history

question

HC medical decision making

answer

high complexity

question

HIM

answer

health information management

question

HIV

answer

human immunodeficiency virus

question

HPI

answer

history of present illness

question

ICU

answer

intensive care unit

question

LC medical decision making

answer

low complexity

question

MU

answer

meaningful use

question

LLQ

answer

left lower quadrant

question

LUQ

answer

left upper quadrant

question

MC medical decision making

answer

moderate complexity

question

MDM

answer

medical decision making

question

NLP

answer

Natural Language Processing

question

NP

answer

new patient

question

NPP

answer

non-physician practitioner

question

PCP

answer

primary care physician

question

PE/PX

answer

physical examination

question

PF level of history or examination

answer

problem focused

question

PFSH

answer

past, family, or social history

question

PH

answer

past history

question

PO

answer

postoperative

question

POMR system

answer

problem-oriented medical record [system]

question

RCU

answer

respiratory care unit

question

RLQ

answer

right lower quadrant

question

R/O

answer

rule out

question

ROS

answer

review of systems

question

RUQ

answer

right upper quadrant

question

SF medical decision making

answer

straightforward

question

SH

answer

social history

question

SNOMED-CT

answer

Systematized Nomenclature of Medicine-clinical terminology

question

SOAP style

answer

subjective objective assessment plan

question

SOR system

answer

source-oriented record [system]

question

WNL

answer

within normal limits

question

Left upper quadrant Left hypochondriac

answer

Liver, stomach, part of the pancreas, parts of the small and large intestines

question

Right and left lumbar

answer

Middle, right, and left regions of the waist

question

Umbilical

answer

Central region near the navel

question

Right lower quadrant Right inguinal

answer

Parts of the small and large intestine, right ovary, right uterine (fallopian) tube, appendix and right ureter

question

Hypogastric

answer

Middle region below the umbilical region contains urinary bladder and female uterus

question

Left lower quadant Left inguinal

answer

Parts of the small intestine, left ovary, left uterine tube, and left ureter

question

Right upper quadant Right hypochondriac

answer

Liver, gallbladder, part of the pancreas, parts of the small and large intestine

question

Epigastric

answer

Upper middle region above the stomach

question

Written or graphic information about patient care is termed a/an

answer

Health record

question

List three of the various types of health record systems that can be used in a medical practice

answer

problem-oriented record (POR) system the source-oriented record (SOR) system integrated record system

question

The difference between an EMR and an EHR is that the _EMR__ is an individual physician's record of the patient's care, wheras the _EHR__ is all of the patient's records, from many different information systems and providers

answer

EMR/EHR

question

The greatest advantage of an EHR system is the improvement of quality of care and patient safety through the _accessibility__of medical records between providers and other health care organizations

answer

accessibility

question

Providers who are not participating in the E-Prescribing Incentive Program in 2014 will have Medicare claims processed with a _2.0__percent adjustment/reduction in their payments

answer

2.0

question

Stage 2 of the Meaningful Use Incentive Program will focus on ___, which will expand the criteria in areas of disease management, clinical decision support, medication management, transitions in care, quality measurement, and research

answer

advanced clinical process

question

What is the CMS definition of legible documentation?

answer

that the data must be easily recognizable by someone outside of the medical practice who is unfamiliar with the handwritting

question

Performance of services or procedures consistent with the diagnosis, done with standards of good medical practice and a proper level of care given in the appropriate setting is known as ___

answer

Medical Necessity

question

Medicare administrative contractors have ___to access a medical practice without an appointment or search warrant to conduct a review of documentation, audits, and evaluations

answer

walk in rights

question

A list of all staff members' names, job titles, signatures, and their initials is known as a/an ___

answer

Signature log

question

For electronic health records, how should an insurance billing specialist correct an error on a patient's record?

answer

note that a section is in error with date and time and enter the correct information with a notation of when and why the physician changed the entry. Authenticate the correction via electronic signature and date. ALSO, could flag record as amended or obsolete and create an addendum either typed as a separate document or for a chart note inserted belowe in the next space availab.e

question

For paper-based records, how should an error be corrected on a patient's record?

answer

Use a permanent ink pen to cross out an incorrect entry on patient's record, mark though it with single line, and write the correct infoeramtion, then date an initial the entry.

question

If a medical practice is audited by Medicare officials and intentional miscoding is discovered, ___may be levied and providers may be ___

answer

...fines and penalties, excluded from Medicare program

question

Name the six documentation components of a patient's history

answer

chief complaint (CC) History of Present illness (HPI) review of systems (ROS) past, family, or social history (PFSH) Documentation Review/Audit Worksheet Documentation of physical examination

question

List the eight descriptive elements that can be documented in the HPI

answer

Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms

question

List the body systems that are recognized for reporting of the ROS

answer

.Constitutional (vital signs, general appearance) Eyes Ears, nose, mouth, and throat Neck Respiratory Cardiovascular Chest, including breasts and axillae Gastrointestinal (abdomen) Genitourinary (male) Genitourinary (female) Lymphatic Musculoskeletal Skin Neurologic Psychiatric

question

A problem-focused examination is a ___examination of the affected body area or organ system

answer

limited

question

MDM is the process performed after taking the patient's history and performing the examination, which results in a ___

answer

plan of treatment

question

Define the following terms in relationship to billing New patient____ Established patient____

answer

An individual who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past 3 years. An individual who has received professional services within the past 3 years from the physician or another physician of the same specialty who belongs to the same group practice

question

Explain the difference between a consultation and the referral of a patient Consultation____ Referral____

answer

Services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problem. The transfer of the total or specific care of a patient from one physician to another. In managed care, a request for authorization for a specific service

question

Medical care for a patient who has received treatment for an illness and is referred to a second physician for treatment of the same condition is a situation called _continuity of care__

answer

continuity of care

question

An emergency medical condition, as defined by Medicare, is a medical condition manifesting itself by _acute symptoms__of __sufficient severity___such that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to body functions, or serious dysfunction of any body organ or part

answer

acute symptoms, sufficient severity

question

Whenever the words "rule out" are used to describe a patient's condition, do not code these conditions as if they existed; instead code the chief _complaint, sign_or _symptom__

answer

chief complaint, sign or symptom

question

Any charts that are amended with additional notes must be labeled "_addendum__" or "late entry" and dated on the day of the amendement, and signed by the physician

answer

addendum

question

If a fax is misdirected, either _telephone__ or _complete a misdirected fax form online__

answer

telephone, complete a misdirected fax form online

question

Renders a service to a patient Directs selection, preparation, and administration of tests, medication, or treatment Legally responsible for the care and treatment given to a patient Gives an opinion regarding a specific problem that is requested by another doctor Sends the patient for tests or treatment or to another doctor for consultation Oversees care of patients in managed care plans and refers patients to see specialists when needed Responsible for training and supervising medical students Clinical nurse specialist or licensed social worker who treats a patient for a specific medical problem and uses the results of a diagnostic test in managing a patient's medical problem Performs one or more years of training in a specialty area while working at a hospital (medical center)

answer

Treating or performing physician Ordering physician Attending physician Consulting physician Referring physician Primary care physician Teaching physician Non-physician provider Resident physician

question

Chart chasing is eliminated when using which type of record system?

answer

Electronic health record system

question

Which of the following is NOT an incentive program for the adoption of EHR?

answer

MPFS

question

Which MU stage focuses on electronically capturing health information into coded format to track conditions, communicate information for care coordination, and report on clinical quality measures and public health information?

answer

Stage 1

question

Regarding the SOAP style of documentation that a physician uses to chart a patient's progress in the health record, SOAP stands for

answer

subjective, objective, assessment, and plan

question

A physical examination of a patient performed by a physician is

answer

comprehensive

question

During the performance of an external audit to review a medical practice's health records, the system used to show deficiencies in documentation is called a/an

answer

SOAP system

question

Which of these elements is a requirement for all levels of history?

answer

CC

question

When there is an underlying disease or other conditions are present at the time of the patient's office visit, this is termed

answer

comorbidity

question

Critical care is rendered in a. d. all of the above

answer

the coronary care unit the intensive care unit the emergency room

question

A patient's hospital discharge summary contains the discharge diagnosis but not the admitting diagnosis

answer

False

question

An eponym should not be used when a comparable anatomic term can be used in its place

answer

True

question

If the phrase "rule out" appears in a patient's health record in connection with a disease, then code the condition as if it exised

answer

False

question

During a prospective review or prebilling audit, all procedures or services and diagnoses listed on the encounter form must match the data on the insurance claim form

answer

True

question

Both civil and criminal subpoenas can be served via a fax machine

answer

False

question

Willful disregard of a subpoena is punishable as contempt of court

answer

True

question

Based on Medicare Conditions of Participation, hospitals must retain medical records for a period of at least 4 years

answer

False

question

Assigned insurance claims for Medicaid and Medicare cases must be kept for a period of 7 years

answer

True

question

If a patient fails to make payment on an overdue account, the physician has the right to formally withdraw from providing care to the patient

answer

True

question

There are very few circumstances that insurance billers may be faced with when executing their job duties that may lead a case of lawsuit

answer

True

question

___Taking or letting out fluids from a body part ___Act of cutting out ___Modifying a body part without affecting function ___Taking out or off a device from a body part ___Stop or attempt to stop bleeding ___Altering the route of passage with anastomoses

answer

Drainage Excision Alteration Removal Control Bypass

question

Write the meaning for these abbreviations and/or symbols commonly encountered in a patient's medical records RLQ DC WNL R/O URI C

answer

right lower quadrant doctor of chiropractic within normal limits rule out Upper Respiratory Infection Comprehensive

question

When documenting incisions, the unit of measure length should be listed in ___

answer

centimeters

question

If a physician called and asked for a patient's medical record STAT, what would he or she mean?

answer

The physician wants the record delivered immediately

question

If a physician asks you to locate the results of the last UA, what would you be searching for?

answer

urinalysis report

question

If a physician telephoned and asked for a copy of the last H & P to be faxed, what is being requested?

answer

History and Physical

question

If a hospital nurse telephoned and asked you to read the results of the patient's last CBC, what would you be searching for?

answer

complete blood count

question

If you were asked to make a photocopy of the patient's last CT, what would you be searching for?

answer

computed tomography scan

question

Acute

answer

A medical condition that runs a short but relatively severe course.

question

Attending Physician

answer

A medical staff member who is legally responsible for the care and treatment given to a patient.

question

Chief Complaint

answer

A patient's statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician.

question

Chronic

answer

A medical condition persisting over a long period of time.

question

Cloned Note

answer

1. Entry in a patient's medical record worded exactly like or similar to the previous entries. 2. Medical documentation that is worded exactly the same from patient to patient. Cloned notes are considered a misrepresentation of the medical necessity requirements for insurance coverage of medical services and can trigger audits.

question

Comorbity

answer

An ongoing condition that exists along with the condition for which the patient is receiving treatment; regarding diagnosis-related groups (DRGs), a preexisting condition that, because of its presence with a certain principal diagnosis, causes an increase in length of stay by at least 1 day in approximately 75% of cases. Also known as substantial comorbidity.

question

Comprehensive

answer

A term used to describe a level of history or physical examination.

question

Concurrent Care

answer

The provision of similar services (for example, hospital visits) to the same patient by more than one physician on the same day. Usually separate physical disorder is present.

question

Consultation

answer

Services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation or treatment of a patient's illness or suspected problem.

question

Consulting Physician

answer

A provider whose opinion or advice about evaluation or management of a specific problem is requested by another physician.

question

Continuity of Care

answer

When a physician sees a patient who has received treatment for a condition and is referred by the previous doctor for treatment of the same condition.

question

Counseling

answer

A discussion between the physician and a patient, family, or both concerning the diagnosis, recommended studies or tests, prognosis, risks, and benefits of treatment, treatment options, patient and family education, and so on.

question

Critical Care

answer

In reference to coding professional services, this phrase relates to intensive care provided in a variety of acute life-threatening conditions requiring constant bedside attention by a physician.

question

Degaussing

answer

Method to dispose of confidential or sensitive information by use of electromagnetic fields to erase data.

question

Detailed

answer

A term used to describe a level of history or physical examinations.

question

Documentation

answer

1. A chronologic detailed recording of pertinent facts and observations about a patient's health as seen in chart notes and medical reports; entries in the medical record, such as prescription refills, telephone calls, and other pertinent data. 2. For computer software, a user's guide to a program or piece of equipment.

question

Electronic Health Record

answer

A patient record that is created using a computer with software. A template is brought up and by answering a series of questions, data are entered.

question

Emergency Care

answer

Health care services provided to prevent serious impairment of bodily functions or serious dysfunction to any body organ or part. Advanced life support may be necessary. Not all care provided in an emergency department of a hospital can be termed "emergency care."

question

Eponym

answer

The name of a disease, anatomic structure, operation, or procedure, usually derived from the name of a place where it first occurred or a person who discovered or first described it.

question

Established Patient

answer

A individual who has received professional services within the past 3 years from the physician or another physician of the same specialty who belongs to the same group patient.

question

Expanded Problem Focused

answer

A phrase used to describe a level of history or physical examination.

question

External Audit

answer

A review done after claims have been submitted (retrospective review) of medical and financial records by an insurance company or Medicare representative to investigate suspected fraud or abusive billing practices.

question

Family History

answer

A review of medical events in a patient's family, including diseases that may be hereditary or place the patient at risk.

question

Health Record/Medical Record

answer

Written or graphic information documenting facts and events during the rendering of patient care. Also known as medical record.

question

High Complexity

answer

A phrase used to describe a type of medical decision making when a patient is seen for an evaluation and management (E/M) service.

question

History of Present Illness

answer

A chronological description of the development of the patient's present illness form the first sign or symptom or from the previous encounter to the present.

question

Internal Review

answer

The process of going over financial documents before and after billing to insurance carriers to determine documentation deficiencies or errors.

question

Legible

answer

Pertaining to a health record, data that is easily recognizable by individuals outside of a medical practice who are unfamiliar with the particular handwriting.

question

Low Complexity

answer

Phrase used to describe a type of medical decision making when a patient is seen for an evaluation and management (E/M) service.

question

Meaningful Use

answer

Able to demonstrate that the health care organization has the capabilities and processes in place so that the provider is actively using certified EHR technology to 1. Improve quality of care, patient safety, and efficiencies in health care and reduce health disparities. 2. Engage patients and family in managements of their care. 3. Improve care coordination and general public health. 4. Maintain the privacy and security of patient's health information.

question

Medical Decision Making

answer

Health care management process done after performing a history and physical examination on a patient that results in a plan of treatment. It is based on establishing one or more diagnoses and/or selecting a management or treatment option, amount of data or complexity of data reviewed, and complications and/or morbidity or mortality.

question

Medical Necessity

answer

The performance of services and procedures that are consistent with the diagnosis in accordance with standards of good medical practice, performed at the proper level, and provided in the most appropriate setting. Medical necessity must be established (via diagnostic or other information presented on the individual claim under consideration) before the carrier may make payment.

question

Medical Report

answer

The performance of services and procedures that are consistent with the diagnosis in accordance with standards of good medical practice, performed at the proper level, and provided in the most appropriate setting. Medical necessity must be established (via diagnostic or other information presented on the individual claim under consideration) before the carrier may make payment.

question

Moderate Complexity

answer

A phrase used to describe a type of medical decision making when a patient is seen for an evaluation and management (E/M) service.

question

New Patient

answer

A phrase used to describe a type of medical decision making when a patient is seen for an evaluation and management (E/M) service.

question

Non-Physician Practitioner

answer

Health care provider who meets state licensing requirements to provide specific medical services. Medicare allows payment for services furnished by NPP's, including but not limited to advance registered nurse practitioners (ARNPs), certified registered nurse practitioners, clinical nurse specialists (CNSs), licensed clinical social workers(LCSWs), physician assistants (PAs), nurse midwives, physical therapists, speech therapists, and audiologists. Also referred to as mid level practitioner, midlevel provider, or physician extender.

question

Ordering Physician

answer

The physician ordering non-physician services for a patient (for example, diagnostic laboratory tests, pharmaceutical services, or durable medical equipment [DME]) when an insurance claim is submitted by a non-physician supplier of services. The ordering physician also may be the treating or performing physician.

question

Past History

answer

A patient's past experiences with illnesses, operations, injuries, and treatments.

question

Physical Examination

answer

Objective inspection or testing of organ systems or body areas of patient by a physician.

question

Prepayment Audit

answer

Review of a submitted claim by an insurance carrier that is pended with a request to the physician to submit a copy of the patient's medical record to support the claim before payment is generated. The insurance carrier reviews the record to determine payment or nonpayment of the claim. Sometimes referred to as prospective audit.

question

Primary Care Physician

answer

A physician (for example, family practitioner, general practitioner, pediatrician,obstetrician/gynecologist, general internist) who oversees the care of patients in a managed healthcare plan (HMO or PPO) and refers patients to specialists (for example, cardiologists, oncologists, surgeons) for services as needed. Also known as a gatekeeper.

question

Problem Focused

answer

A phrase used to describe a type of medical decision making when a patient is seen for an evaluation and management (E/M) service.

question

Prospective Review

answer

The process of going over financial documents before billing is submitted to the insurance company to determine documentation deficiencies and errors.

question

Referral

answer

The transfer of the total or specific care of a patient from one physician to another. In managed care, a request for authorization for a specific service.

question

Referring Physician

answer

A physician who sends the patient for testing or treatment noted on the insurance claim when it is submitted by the physician performing the service.

question

Resident Physician

answer

A physician who has finished medical school and is performing one or more years of training in a specialty area on the job at a hospital (medical center).

question

Retrospective Review

answer

The process of going over financial document after billing an insurance carrier to determine documentation deficiencies and errors.

question

Review of Systems

answer

An inventory of body systems obtained through a series of questions used to identify signs or symptoms that the patient might be experiencing or has experienced.

question

Social History

answer

An age-appropriate review of a patient's past and current activities (for example, smoking, diet intake, alcohol use).

question

Straightforward

answer

Phrase used to describe a type of medical decision making when a patient is seen for an evaluation and management (E/M) service.

question

Subpoena

answer

"Under penalty." A writ that commands a witness to appear at a trial or other proceeding and give testimony.

question

Subpoena Duces Tecum

answer

"In his possession." A subpoena that requires the appearance of a witness with his or her records. Sometimes the judge permits the mailing of records and it is not necessary for the physician to appear in court.

question

Teaching Physician

answer

A physician who is responsible for training and supervising medical students, inters, or residents and who takes them to the bedsides of patients in a teaching hospital to review course and treatment.

question

Treating, or performing, Physician

answer

A provider who renders a service to a patient.

question

Zeroization

answer

Method to dispose of confidential or sensitive information by writing repeated sequences of ones and zeros over the data.

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