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NHA- (CEHRS) Electronic Health Records
Specialist Questions and Answers
When abstracting from an outpatient record to assign the ICD-9-
CM code, which of the following should an EHR specialist look for?
Ans: Diagnosis listed first in the documentation
Surgical procedure codes
Ans: Surgical procedure codes with a 2-digit classification followed by
one or two digits are in the ICD-9-CM manual and are used for coding
inpatient procedures.
Current Procedural Terminology (CPT) codes —
Ans: Numeric codes developed by the American Medical Association
(AMA) to standardize medical services and procedures
Encounter form —
Ans: A form the provider fills out as she sees the patient; lists the
service charges and how much the patient paid for the services; can be
submitted for billing
Face sheet —
Ans: A standard structured document that contains patient information,
such as name, date of birth, insurance information, reason for seeking
medical care, and religious preference; medical staff uses the document
to quickly see the relevant points for patient care
Healthcare Common Procedure Coding System (HCPCS) —
Ans: A numeric and alphabetic coding system used for billing and
pricing of procedures, medical supplies, medications, and durable
medical equipment
© 2025 All rights reserved
NHA- (CEHRS) Electronic Health Records
Specialist Questions and Answers
When abstracting from an outpatient record to assign the ICD-9-
CM code, which of the following should an EHR specialist look for?
Ans: Diagnosis listed first in the documentation
Surgical procedure codes
Ans: Surgical procedure codes with a 2-digit classification followed by
one or two digits are in the ICD-9-CM manual and are used for coding
inpatient procedures.
Current Procedural Terminology (CPT) codes —
Ans: Numeric codes developed by the American Medical Association
(AMA) to standardize medical services and procedures
Encounter form —
Ans: A form the provider fills out as she sees the patient; lists the
service charges and how much the patient paid for the services; can be
submitted for billing
Face sheet —
Ans: A standard structured document that contains patient information,
such as name, date of birth, insurance information, reason for seeking
medical care, and religious preference; medical staff uses the document
to quickly see the relevant points for patient care
Healthcare Common Procedure Coding System (HCPCS) —
Ans: A numeric and alphabetic coding system used for billing and
pricing of procedures, medical supplies, medications, and durable
medical equipment
© 2025 All rights reserved
