Ch. 4 Medical Documentation and the Electronic Health Record exam questions and answers.

True or False During an audit, points are awarded when documentation is present. True True or False Private insurance carriers have the right to claim refunds in the event of accidental miscoding. True True or False A problem- focused examination is more complex than a detailed examination False True or False An established patient is anyone who has previously received professional services from the physician or another physician of the same specialty who belongs to the group practice. False True or False A consultation may take place in a home, office, hospital, or extended care facility. True True or False An edit check is a good audit prevention measure to have in place True The key to substantiating procedure and diagnostic code selections for proper reimbursement is supporting documentation in the electronic health record An electronic medical record report is Permanent legal document, and part of the health record An advantage of electronic medical records is greater standardization in clinical medical terminology When each entry in the medical record is worded similar to the previous entries, this is considered documentation. Cloned Under Medicare incentive program for implementation of EHR (Electronic Health Record), eligible providers will__________ demonstrated MU(Meaningful Use). Be penalized through payment adjustments starting in 2015 if they have not. The chronological recording of pertinent facts and observations about the patient's health is known as Documentation Reasons for documentation are Defense of professional liability claim, and insurance carriers require accurate documentation that supports procedure and diagnostic codes. The SOAP in patient medical record charting may be defined as S- Subjective O- Objective A- Assessment P-Plan When a patient fails to return for needed treatment, documentation should be made in the patient's medical record, in the appointment book, on the financial record or ledger card. How should an entry in a patient's electronic medical record be corrects? input a note of which section is in error and enter correct data with details of why the correction is necessary and authenticate with electronic signature, date, and time. a concise statement describing the symptom, problem,condition, diagnosis, physician- recommended return, or or other factor that is the reason for the encounter is abbreviated as CC- Chief Complaint Levels of evaluation and management services are based on type(s) of physical examination that may be Problem-focused An expanded problem-focused examination is a(n) Limited examination of the affected body area A diseased condition or state is known as Morbidity what does comorbidity mean? Underlying diseases or other conditions present at the time of the visit An new patient is one who has not received any professional services from the physician within the last 3 years An established patient is one who has previously received professional services from a physician or another physician of the same specialty who belongs to the group practice within the past 3 years In dealing with managed care plans, a referral is the same as a consultation, and transfer of the total or specific care of a patient from one physician to another. When a discussion takes place with a patient concerning the risks and benefits of treatment options, it is considered Counseling Your physician has been to the hospital providing constant bedside attention and treating a patient in respiratory failure. These services are considered critical care The official American Hospital Association policy states that abbreviations should be totally eliminated from the more vital sections of the record, such as the final diagnosis, operative notes, discharge summaries