CRC final exam study guide Questions and answers,100% Accurate, Graded A+

CRC final exam study guide Questions and answers,100% Accurate, Graded A+ Health record (Medical Record) - -Written or graphic information documenting the facts and events during the rendering of patient care. SOAP notes - -Office visit notes organized into four sections: Subjective, Objective, Assessment, Plan EMR - -An electronic file wherein patients health information from a single medical provider is stored in a computer system EHR - -A computerized lifelong healthcare record for and individual that incorporates data from all providers who treat the individual. EHR advantages - -Accessibility between providers improves quality of care; Cost savings and increased efficiency; Requires no physical storage; Reduced charting errors; Automatic data capture Attending physician - -Hospital staff member who is legally responsible for care and treatment given to a patient Legible documentation requirement - -Info in the health record must be easily recognizable by someone outside of the medical practice who is unfamiliar with the handwriting. Internal Audits - -Audits performed by a staff member of the practice or by a hired consultant to uncover problems in coding and billing compliance so they can be corrected. Prospective Review - -Review of billing and coding completed BEFORE claims are submitted. Retrospective Review - -Internal review of billing and coding completed AFTER claims are submitted and after ins co has responded. Compliance Plan - -A medical practice's written policies for complying with payer and government regulations in order to avoid fraud and abuse. Collections Specialist - -Staff member trained to work with patients to resolve overdue bills. Financial policy - -The medical practice's clear explanation of billing procedures and financial rules, which should be signed by all patients. Physician fee schedule - -Service fees must be the same for all patients and and a list of common services, descriptions, and fees must be available to all patients. Missed appointment fees - -Typically $35-50, due from the patient. Cash patients - -A discount may be offered to all patients who pay cash up front (self pays).