ARRA
American Recovery and Reinvestment Act
C level of history or examination
comprehensive [level of history or examination]
CC
chief complaint
CCU
coronary care unit
D level of history or examination
detailed
dx/Dx
diagnosis
ED/ER
emergency department or emergency room
EHR
electronic health record
E/M service
evaluation and management
EMR
electronic medical record
EPF level of history or examination
expanded problem focused
ESI
Electronically stored information
fax
Facsimile
FH
family history
HC medical decision making
high complexity
HIM
health information management
HIV
human immunodeficiency virus
HPI
history of present illness
ICU
intensive care unit
LC medical decision making
low complexity
MU
meaningful use
LLQ
left lower quadrant
LUQ
left upper quadrant
MC medical decision making
moderate complexity
MDM
medical decision making
NLP
Natural Language Processing
NP
new patient
NPP
non-physician practitioner
PCP
primary care physician
PE/PX
physical examination
PF level of history or examination
problem focused
PFSH
past, family, or social history
PH
past history
PO
postoperative
POMR system
problem-oriented medical record [system]
RCU
respiratory care unit
RLQ
right lower quadrant
R/O
rule out
ROS
review of systems
RUQ
right upper quadrant
SF medical decision making
straightforward
SH
social history
SNOMED-CT
Systematized Nomenclature of Medicine-clinical terminology
SOAP style
subjective objective assessment plan
SOR system
source-oriented record [system]
WNL
within normal limits
Left upper quadrant Left hypochondriac
Liver, stomach, part of the pancreas, parts of the small and large intestines
Right and left lumbar
Middle, right, and left regions of the waist
Umbilical
Central region near the navel
Right lower quadrant Right inguinal
Parts of the small and large intestine, right ovary, right uterine (fallopian) tube, appendix and right ureter
Hypogastric
Middle region below the umbilical region contains urinary bladder and female uterus
Left lower quadant Left inguinal
Parts of the small intestine, left ovary, left uterine tube, and left ureter
Right upper quadant Right hypochondriac
Liver, gallbladder, part of the pancreas, parts of the small and large intestine
Epigastric
Upper middle region above the stomach
Written or graphic information about patient care is termed a/an
Health record
List three of the various types of health record systems that can be used in a medical practice
problem-oriented record (POR) system the source-oriented record (SOR) system integrated record system
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
EMR/EHR
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
accessibility
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
2.0
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
advanced clinical process
What is the CMS definition of legible documentation?
that the data must be easily recognizable by someone outside of the medical practice who is unfamiliar with the handwritting
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 ___
Medical Necessity
Medicare administrative contractors have ___to access a medical practice without an appointment or search warrant to conduct a review of documentation, audits, and evaluations
walk in rights
A list of all staff members' names, job titles, signatures, and their initials is known as a/an ___
Signature log
For electronic health records, how should an insurance billing specialist correct an error on a patient's record?
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
For paper-based records, how should an error be corrected on a patient's record?
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.
If a medical practice is audited by Medicare officials and intentional miscoding is discovered, ___may be levied and providers may be ___
...fines and penalties, excluded from Medicare program
Name the six documentation components of a patient's history
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
List the eight descriptive elements that can be documented in the HPI
Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms
List the body systems that are recognized for reporting of the ROS
.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
A problem-focused examination is a ___examination of the affected body area or organ system
limited
MDM is the process performed after taking the patient's history and performing the examination, which results in a ___
plan of treatment
Define the following terms in relationship to billing New patient____ Established patient____
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
Explain the difference between a consultation and the referral of a patient Consultation____ Referral____
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
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__
continuity of care
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
acute symptoms, sufficient severity
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__
chief complaint, sign or symptom
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
addendum
If a fax is misdirected, either _telephone__ or _complete a misdirected fax form online__
telephone, complete a misdirected fax form online
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)
Treating or performing physician Ordering physician Attending physician Consulting physician Referring physician Primary care physician Teaching physician Non-physician provider Resident physician
Chart chasing is eliminated when using which type of record system?
Electronic health record system
Which of the following is NOT an incentive program for the adoption of EHR?
MPFS
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?
Stage 1
Regarding the SOAP style of documentation that a physician uses to chart a patient's progress in the health record, SOAP stands for
subjective, objective, assessment, and plan
A physical examination of a patient performed by a physician is
comprehensive
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
SOAP system
Which of these elements is a requirement for all levels of history?
CC
When there is an underlying disease or other conditions are present at the time of the patient's office visit, this is termed
comorbidity
Critical care is rendered in a. d. all of the above
the coronary care unit the intensive care unit the emergency room
A patient's hospital discharge summary contains the discharge diagnosis but not the admitting diagnosis
False
An eponym should not be used when a comparable anatomic term can be used in its place
True
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
False
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
True
Both civil and criminal subpoenas can be served via a fax machine
False
Willful disregard of a subpoena is punishable as contempt of court
True
Based on Medicare Conditions of Participation, hospitals must retain medical records for a period of at least 4 years
False
Assigned insurance claims for Medicaid and Medicare cases must be kept for a period of 7 years
True
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
True
There are very few circumstances that insurance billers may be faced with when executing their job duties that may lead a case of lawsuit
True
___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
Drainage Excision Alteration Removal Control Bypass
Write the meaning for these abbreviations and/or symbols commonly encountered in a patient's medical records RLQ DC WNL R/O URI C
right lower quadrant doctor of chiropractic within normal limits rule out Upper Respiratory Infection Comprehensive
When documenting incisions, the unit of measure length should be listed in ___
centimeters
If a physician called and asked for a patient's medical record STAT, what would he or she mean?
The physician wants the record delivered immediately
If a physician asks you to locate the results of the last UA, what would you be searching for?
urinalysis report
If a physician telephoned and asked for a copy of the last H & P to be faxed, what is being requested?
History and Physical
If a hospital nurse telephoned and asked you to read the results of the patient's last CBC, what would you be searching for?
complete blood count
If you were asked to make a photocopy of the patient's last CT, what would you be searching for?
computed tomography scan
Acute
A medical condition that runs a short but relatively severe course.
Attending Physician
A medical staff member who is legally responsible for the care and treatment given to a patient.
Chief Complaint
A patient's statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician.
Chronic
A medical condition persisting over a long period of time.
Cloned Note
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.
Comorbity
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.
Comprehensive
A term used to describe a level of history or physical examination.
Concurrent Care
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.
Consultation
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.
Consulting Physician
A provider whose opinion or advice about evaluation or management of a specific problem is requested by another physician.
Continuity of Care
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.
Counseling
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.
Critical Care
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.
Degaussing
Method to dispose of confidential or sensitive information by use of electromagnetic fields to erase data.
Detailed
A term used to describe a level of history or physical examinations.
Documentation
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.
Electronic Health Record
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.
Emergency Care
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."
Eponym
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.
Established Patient
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.
Expanded Problem Focused
A phrase used to describe a level of history or physical examination.
External Audit
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.
Family History
A review of medical events in a patient's family, including diseases that may be hereditary or place the patient at risk.
Health Record/Medical Record
Written or graphic information documenting facts and events during the rendering of patient care. Also known as medical record.
High Complexity
A phrase used to describe a type of medical decision making when a patient is seen for an evaluation and management (E/M) service.
History of Present Illness
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.
Internal Review
The process of going over financial documents before and after billing to insurance carriers to determine documentation deficiencies or errors.
Legible
Pertaining to a health record, data that is easily recognizable by individuals outside of a medical practice who are unfamiliar with the particular handwriting.
Low Complexity
Phrase used to describe a type of medical decision making when a patient is seen for an evaluation and management (E/M) service.
Meaningful Use
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.
Medical Decision Making
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.
Medical Necessity
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.
Medical Report
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.
Moderate Complexity
A phrase used to describe a type of medical decision making when a patient is seen for an evaluation and management (E/M) service.
New Patient
A phrase used to describe a type of medical decision making when a patient is seen for an evaluation and management (E/M) service.
Non-Physician Practitioner
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.
Ordering Physician
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.
Past History
A patient's past experiences with illnesses, operations, injuries, and treatments.
Physical Examination
Objective inspection or testing of organ systems or body areas of patient by a physician.
Prepayment Audit
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.
Primary Care Physician
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.
Problem Focused
A phrase used to describe a type of medical decision making when a patient is seen for an evaluation and management (E/M) service.
Prospective Review
The process of going over financial documents before billing is submitted to the insurance company to determine documentation deficiencies and errors.
Referral
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.
Referring Physician
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.
Resident Physician
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).
Retrospective Review
The process of going over financial document after billing an insurance carrier to determine documentation deficiencies and errors.
Review of Systems
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.
Social History
An age-appropriate review of a patient's past and current activities (for example, smoking, diet intake, alcohol use).
Straightforward
Phrase used to describe a type of medical decision making when a patient is seen for an evaluation and management (E/M) service.
Subpoena
"Under penalty." A writ that commands a witness to appear at a trial or other proceeding and give testimony.
Subpoena Duces Tecum
"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.
Teaching Physician
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.
Treating, or performing, Physician
A provider who renders a service to a patient.
Zeroization
Method to dispose of confidential or sensitive information by writing repeated sequences of ones and zeros over the data.