SCRIBE TRAINING COURSE EXAM
QUESTIONS AND ANSWERS
Diagnostic Tools - Answer-Pg 39-43
ROS Terminology - Answer-Pg 46-58
HIPAA coding systems (3) - Answer-E/M coding system
CPT coding system
ICD-9/10-CM
E/M coding system - Answer-The evaluation and management coding system. How
providers are billed in order to get reimbursement
CPT coding system - Answer-Current procedural terminology coding system. To
communicate uniform information about medical services and procedures among
physicians, billing, puts, accreditation organizarions
ICD9/10CM - Answer-International classification of diseases. The diagnosis
classification. Every disease has a code linked to reimbursement
What is CMS - Answer-The centers for Medicare and Medicaid services. A federal
agency that administers Medicare and Medicaid programs and oversees HIPAA
Medicare - Answer-Government program for elderly
Medicaid - Answer-Government program for those unable to afford regular medical
services
CMS & Meaningful Use - Answer-It regulates electronic health record incentive
programs to provide financial incentives for meaningful use.
EHR Stage 1 meaningful use - Answer-Core requirements: use computerized order
entry for medication orders, implement drug-drug checks, record demographics,
maintain an active medication lists, maintain an active medication allergy list, record
smoking status for pt 13 years of age and older
Menu requirements: implement drug-formulary checks, send reminders to patients per
pt preference for preventative and follow up care
EHR Stage 2 meaningful use - Answer-Core requirements: computerized provider order
entry, eRx, record changes in vital signs, smoking status, protect electronic health
information, educational resources, reminders for preventative/follow-up care
Menu requirements: electronic notes, access to imaging results, family health history,
cancer cases, specific cases
, PQRS - Answer-The physician quality reporting system. It is a reporting program that
gives out incentives to report data on quality measures for covered professional
services. Ex: #pt with heart attacks, #pts with diabetes
TJC core measure sets: (14) - Answer-Heart failure (HF)
Venous thromboembolism (VTE)
Emergency department
Surgical care improvement project
Substance use
Tobacco treatment
Immunization
Children's asthma care
Stroke
Acute Myocardial Infraction
ICD - Answer-International Classification of Disease provides a system of diagnostic
codes for classifying diseases that may be used for diagnostic and billing purposes
CPT - Answer-Current Procedural Terminology codes are associated with services and
procedures provided in an encounter in the outpatient facility
E/M coding assignments (3) - Answer-Place of service
Type of service
Patient status
Place of service - Answer-Office, hospital, ER
Type of service - Answer-Office visit, consultation, hospital admission, newborn care
Patient status - Answer-NP, established, outpatient, inpatient
3 key components that determine the E/M level of service - Answer-History (HPI, PFSH,
ROS)
Examination (PE)
MDM
3 contributory factors that determine the E/M level of service - Answer-Coordination of
care (care with other physicians ex referral)
Nature of presenting problem (how severe the problem is)
FaceTime (time spent with pt)
History component of E/M - Answer-Problem-Focused
Expanded Problem-Focused
Detailed
Comprehensive
QUESTIONS AND ANSWERS
Diagnostic Tools - Answer-Pg 39-43
ROS Terminology - Answer-Pg 46-58
HIPAA coding systems (3) - Answer-E/M coding system
CPT coding system
ICD-9/10-CM
E/M coding system - Answer-The evaluation and management coding system. How
providers are billed in order to get reimbursement
CPT coding system - Answer-Current procedural terminology coding system. To
communicate uniform information about medical services and procedures among
physicians, billing, puts, accreditation organizarions
ICD9/10CM - Answer-International classification of diseases. The diagnosis
classification. Every disease has a code linked to reimbursement
What is CMS - Answer-The centers for Medicare and Medicaid services. A federal
agency that administers Medicare and Medicaid programs and oversees HIPAA
Medicare - Answer-Government program for elderly
Medicaid - Answer-Government program for those unable to afford regular medical
services
CMS & Meaningful Use - Answer-It regulates electronic health record incentive
programs to provide financial incentives for meaningful use.
EHR Stage 1 meaningful use - Answer-Core requirements: use computerized order
entry for medication orders, implement drug-drug checks, record demographics,
maintain an active medication lists, maintain an active medication allergy list, record
smoking status for pt 13 years of age and older
Menu requirements: implement drug-formulary checks, send reminders to patients per
pt preference for preventative and follow up care
EHR Stage 2 meaningful use - Answer-Core requirements: computerized provider order
entry, eRx, record changes in vital signs, smoking status, protect electronic health
information, educational resources, reminders for preventative/follow-up care
Menu requirements: electronic notes, access to imaging results, family health history,
cancer cases, specific cases
, PQRS - Answer-The physician quality reporting system. It is a reporting program that
gives out incentives to report data on quality measures for covered professional
services. Ex: #pt with heart attacks, #pts with diabetes
TJC core measure sets: (14) - Answer-Heart failure (HF)
Venous thromboembolism (VTE)
Emergency department
Surgical care improvement project
Substance use
Tobacco treatment
Immunization
Children's asthma care
Stroke
Acute Myocardial Infraction
ICD - Answer-International Classification of Disease provides a system of diagnostic
codes for classifying diseases that may be used for diagnostic and billing purposes
CPT - Answer-Current Procedural Terminology codes are associated with services and
procedures provided in an encounter in the outpatient facility
E/M coding assignments (3) - Answer-Place of service
Type of service
Patient status
Place of service - Answer-Office, hospital, ER
Type of service - Answer-Office visit, consultation, hospital admission, newborn care
Patient status - Answer-NP, established, outpatient, inpatient
3 key components that determine the E/M level of service - Answer-History (HPI, PFSH,
ROS)
Examination (PE)
MDM
3 contributory factors that determine the E/M level of service - Answer-Coordination of
care (care with other physicians ex referral)
Nature of presenting problem (how severe the problem is)
FaceTime (time spent with pt)
History component of E/M - Answer-Problem-Focused
Expanded Problem-Focused
Detailed
Comprehensive
