TAUC PF PRE-SCRIBE U UPDATED QUESTIONS AND VERIFIED ANSWERS
What should be consistently documented in the Procedures section for billing purposes? - CORRECT
ANSWER✅✅✅Prescription medication discussions
Review of outside diagnostic results
Discussions with external professionals
Independent historians needed
What is included in the prescription medication discussions? - CORRECT ANSWER✅✅✅Document ll
discussions regarding any prescription medicine that the patient is already taking whenever it is relevant
to the current condition
- Ex. BP meds for pt who is hypertensive
Document when a pt refuses a prescription medicine recommended
What is included in review of outside diagnostic results? - CORRECT ANSWER✅✅✅Whenever a
patient shows you outside labs or radiology results and asks you questions about them... Document:
outside lab results reviewed and showed (insert interpretation)
When documenting discussions with external professionals what must you include? - CORRECT
ANSWER✅✅✅Document any conversations you have with external sources such as:
-ER triage nurse
-Urgent specialist
-External provider involved w/ pts care
-Non-healthcare professionals involved in pts management
What do you document when independent historians are needed? - CORRECT ANSWER✅✅✅When
a pt is unable to provide a complete or reliable hx document discussions with another historian
When selecting a dx modifier what should you not do? - CORRECT ANSWER✅✅✅Do not select any
of the three choices in the top under "uses for coding"
-uncomplicated
-systemic symptoms
, -poses a threat to life or bodily functions
What do you select instead when selecting a dx modifier? - CORRECT ANSWER✅✅✅Choose the
numbered choices from the bottom section (top 4)
-Acute
-Chronic
-Incidental lesion/mass
Bottoms 6 are additions to top 4
What should all fractures be referred to as? - CORRECT ANSWER✅✅✅Clinical not possible and you
must include an associated fracture dx
Should you document any refused procedures in the procedure note? - CORRECT ANSWER✅✅✅yes
Can diagnosis modifiers be modified at a later time? - CORRECT ANSWER✅✅✅Yes in the diagnosis
screen by clicking on "dx mod" button
Are charts coded by providers? - CORRECT ANSWER✅✅✅No
What do you do if the common diagnosis list does not contain the diagnosis you need? - CORRECT
ANSWER✅✅✅You can use the ICD-10 search function
-Type the diagnosis you are searching for, select from list, this will take you to the next screen
-Select a second more accurate diagnosis on the second screen
After you select the diagnosis, what must you specify in the next screen? - CORRECT
ANSWER✅✅✅Laterality, visit number, further specification of anatomy
What can you do if you are unable to locate the exact diagnosis? - CORRECT ANSWER✅✅✅Rename
the diagnosis by typing in the rename bar
What should be consistently documented in the Procedures section for billing purposes? - CORRECT
ANSWER✅✅✅Prescription medication discussions
Review of outside diagnostic results
Discussions with external professionals
Independent historians needed
What is included in the prescription medication discussions? - CORRECT ANSWER✅✅✅Document ll
discussions regarding any prescription medicine that the patient is already taking whenever it is relevant
to the current condition
- Ex. BP meds for pt who is hypertensive
Document when a pt refuses a prescription medicine recommended
What is included in review of outside diagnostic results? - CORRECT ANSWER✅✅✅Whenever a
patient shows you outside labs or radiology results and asks you questions about them... Document:
outside lab results reviewed and showed (insert interpretation)
When documenting discussions with external professionals what must you include? - CORRECT
ANSWER✅✅✅Document any conversations you have with external sources such as:
-ER triage nurse
-Urgent specialist
-External provider involved w/ pts care
-Non-healthcare professionals involved in pts management
What do you document when independent historians are needed? - CORRECT ANSWER✅✅✅When
a pt is unable to provide a complete or reliable hx document discussions with another historian
When selecting a dx modifier what should you not do? - CORRECT ANSWER✅✅✅Do not select any
of the three choices in the top under "uses for coding"
-uncomplicated
-systemic symptoms
, -poses a threat to life or bodily functions
What do you select instead when selecting a dx modifier? - CORRECT ANSWER✅✅✅Choose the
numbered choices from the bottom section (top 4)
-Acute
-Chronic
-Incidental lesion/mass
Bottoms 6 are additions to top 4
What should all fractures be referred to as? - CORRECT ANSWER✅✅✅Clinical not possible and you
must include an associated fracture dx
Should you document any refused procedures in the procedure note? - CORRECT ANSWER✅✅✅yes
Can diagnosis modifiers be modified at a later time? - CORRECT ANSWER✅✅✅Yes in the diagnosis
screen by clicking on "dx mod" button
Are charts coded by providers? - CORRECT ANSWER✅✅✅No
What do you do if the common diagnosis list does not contain the diagnosis you need? - CORRECT
ANSWER✅✅✅You can use the ICD-10 search function
-Type the diagnosis you are searching for, select from list, this will take you to the next screen
-Select a second more accurate diagnosis on the second screen
After you select the diagnosis, what must you specify in the next screen? - CORRECT
ANSWER✅✅✅Laterality, visit number, further specification of anatomy
What can you do if you are unable to locate the exact diagnosis? - CORRECT ANSWER✅✅✅Rename
the diagnosis by typing in the rename bar
