CRC final exam study guide questions
format questions & answered.
What is the collection of written or graphic information documenting the facts and events during the
rendering of patient care? ANS -Health record (or Medical Record)
What are the four sections of a SOAP office visit note? ANS -Subjective, Objective, Assessment, Plan
What is an electronic file wherein patients health information from a single medical provider is stored in
a computer system? ANS -EMR
What does EMR stand for? ANS -Electronic Medical Record
What is a computerized lifelong healthcare record for and individual that incorporates data from all
providers who treat the individual? ANS -EHR
What does EHR stand for? ANS -Electronic Health Record
What are the advantages of EHR? ANS -1) Accessibility between providers improves quality of care; 2)
Cost savings and increased efficiency; 3) Requires no physical storage; 4) Reduced charting errors; 5)
Automatic data capture
Which hospital staff member is legally responsible for care and treatment given to an inpatient? ANS -
Attending physician
What is the legible documentation requirement? ANS -Info in the health record must be easily
recognizable by someone outside of the medical practice who is unfamiliar with the handwriting.
What audits are 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? ANS -Internal Audits
, What internal review of billing and coding is completed BEFORE claims are submitted? ANS -Prospective
Review
What internal review of billing and coding is completed AFTER claims are submitted and after ins co has
responded? ANS -Retrospective Review
What is a medical practice's set of written policies for complying with payer and government regulations
in order to avoid fraud and abuse? ANS -Compliance Plan
Which staff member is trained to work with patients to resolve overdue bills? ANS -Collections Specialist
What is the medical practice's clear explanation of billing procedures and financial rules, which should
be signed by all patients? ANS -Financial policy
What two rules apply to the physician fee schedule? ANS -1) Service fees must be the same for all
patients.
2) A list of common services, descriptions, and fees must be available to all patients.
What amount is the typical missed appointment fee, and who is responsible to pay it? ANS -$35-50, due
from the patient (not ins co).
Can a discount be offered to patients paying cash up front? ANS -Yes, a discount may be offered to all
patients who pay cash up front (self pays).
Can a discount be offered to patients who have a financial hardship? ANS -Yes, the hardship must be
proven and documented, and discounts must be equally available to all patients based on financial need.
What term refers to the questionable practice of offering reduced or free services to medical
professionals or their families? ANS -Professional courtesy
format questions & answered.
What is the collection of written or graphic information documenting the facts and events during the
rendering of patient care? ANS -Health record (or Medical Record)
What are the four sections of a SOAP office visit note? ANS -Subjective, Objective, Assessment, Plan
What is an electronic file wherein patients health information from a single medical provider is stored in
a computer system? ANS -EMR
What does EMR stand for? ANS -Electronic Medical Record
What is a computerized lifelong healthcare record for and individual that incorporates data from all
providers who treat the individual? ANS -EHR
What does EHR stand for? ANS -Electronic Health Record
What are the advantages of EHR? ANS -1) Accessibility between providers improves quality of care; 2)
Cost savings and increased efficiency; 3) Requires no physical storage; 4) Reduced charting errors; 5)
Automatic data capture
Which hospital staff member is legally responsible for care and treatment given to an inpatient? ANS -
Attending physician
What is the legible documentation requirement? ANS -Info in the health record must be easily
recognizable by someone outside of the medical practice who is unfamiliar with the handwriting.
What audits are 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? ANS -Internal Audits
, What internal review of billing and coding is completed BEFORE claims are submitted? ANS -Prospective
Review
What internal review of billing and coding is completed AFTER claims are submitted and after ins co has
responded? ANS -Retrospective Review
What is a medical practice's set of written policies for complying with payer and government regulations
in order to avoid fraud and abuse? ANS -Compliance Plan
Which staff member is trained to work with patients to resolve overdue bills? ANS -Collections Specialist
What is the medical practice's clear explanation of billing procedures and financial rules, which should
be signed by all patients? ANS -Financial policy
What two rules apply to the physician fee schedule? ANS -1) Service fees must be the same for all
patients.
2) A list of common services, descriptions, and fees must be available to all patients.
What amount is the typical missed appointment fee, and who is responsible to pay it? ANS -$35-50, due
from the patient (not ins co).
Can a discount be offered to patients paying cash up front? ANS -Yes, a discount may be offered to all
patients who pay cash up front (self pays).
Can a discount be offered to patients who have a financial hardship? ANS -Yes, the hardship must be
proven and documented, and discounts must be equally available to all patients based on financial need.
What term refers to the questionable practice of offering reduced or free services to medical
professionals or their families? ANS -Professional courtesy
